An ever-increasing dilemma in nursing education is teaching reasoning in the university setting and ensuring its transfer to clinical practice (Andrews & Jones, 1996; Chun-Heung & French, 1997; Jeffries, 2005). Diverse teaching and learning approaches are required to facilitate the development of mental representations of a range of current clinical situations. The use of high-fidelity simulation as one offering of a smorgasbord of teaching and learning methods can facilitate the development of students’ cognitive, associative, and psychomotor skills in a safe, nonthreatening, effective, and realistic environment (Feingold, Calaluce, & Kallen, 2004; Good, 2003; Terman, 2007).
This evaluative cohort study explored the perceptions of third-year nursing students (N = 300) about the implementation of high-fidelity simulation using SimMan® into an existing clinical course.
Nursing education promotes the development of psychomotor skills, critical thinking, self-confidence, and the ability to integrate theory into practice (Espeland & Indrehus, 2003). Research consistently demonstrates nursing graduates’ deficits in psychomotor and technical skills, and their competence and confidence in clinical decision making (Gerrish, 2000; Lawson, Alinier, & Jones, 2006; Schoening, Sittner, & Todd, 2006; Semple, Cook, Moseley, & Torrance, 2001; Torrance & Serginson, 1996; White, Bull, Pitzner, & Kelly, 2005).
Although clinical skills laboratories were instituted to assist students’ practice of psychomotor skills (Medley & Horne, 2005; Schoening et al., 2006), their success in the transfer of skills into the reality of clinical practice and the facilitation of clinical decision making is questionable. Nursing students have stated that they learn best by interaction with real patients in the clinical environment (Medley & Horne, 2005; Rakoczy & Money, 1995). A predominant focus on hands-on skills and the lack of timely reflection in the clinical setting negates opportunities to develop mental representations required for pattern recognition and clinical reasoning (Thornton, 1997).
The use of high-fidelity simulation has the potential to assist students in the development of mental representations through the process of pattern recognition and cognitive inference. Cognitive inference, the rapid and subliminal evaluation and interpretation of visual and verbal cues into recognized patterns (Offredy, 1998), is acquired through a combination of years of nursing experience and reflection on this experience. Activities to promote pattern recognition must contain essential features of a particular clinical situation (Nosofsky & Palmeri, 1997) and incorporate visual, verbal, and written cues (Norman, Brooks, Regehr, Marriott, & Shali, 1996), which are all features of a well-designed high-fidelity simulation.
The incorporation of high-fidelity simulation into the undergraduate nursing curriculum possesses the potential to enhance experiential learning, skill acquisition, problem solving abilities, teamwork (Alinier, Hunt, Gordon, & Harwood, 2006), and critical thinking (Feingold et al., 2004; Medley & Horne, 2005). High-fidelity simulation exposes students to patients’ responses to nursing actions for problems often not encountered in their clinical placements. This experience, when combined with reflection (debriefing), supports the aims of cognitive learning theory in its promotion of student interaction with clinical cases, use of prior knowledge, and the development and consolidation of mental representations (Johnson, Zerwic, & Theis, 1999; Lasater, 2007).
High-fidelity clinical simulation provides a controlled, reproducible, standardized, and nonthreatening environment (Feingold et al., 2004; Good, 2003; Issenberg, McGaghie, Petrusa, Gordon, & Scalese, 2005; Rosenthal et al., 2006) where variables can be predetermined and controlled and learning time maximized (Friedrich, 2002). High-fidelity simulators imitate most physiological responses and enable the simulated patient to initiate conversation and respond verbally to students (Good, 2003; Medley & Horne, 2005).
The use of high-fidelity simulation enhances students’ self-confidence and increases retention and transference of knowledge to the clinical setting (Feingold et al., 2004; Terman, 2007). Students’ positive perceptions and enjoyment of simulation, which increase retention and reinforce knowledge (Herrman, 2002; Skiba, 1997), are not decreased by concurrent feelings of anxiety and inadequacy during simulation (Lasater, 2007). Of concern, however, is the results of one study in which simulation was seen as realistic and valuable, but only 50% of students believed the skills learned were transferable to the clinical setting (Feingold et al., 2004).
Debriefing describes a situation that moves beyond talking to the process of analysis of a response to a particular situation to the development of knowledge and understanding of the appropriateness of participants’ actions, reasons for those actions, and identification of strategies for future application in similar situations (Fanning & Gaba, 2007; Issenberg et al., 2005; Lasater, 2007). Whereas debriefing is often not a predominant feature of students’ performance in the clinical setting (Johnson et al., 1999), it is the linchpin to successful high-fidelity simulation (Issenberg et al., 2005).
The timing of such debriefing is also extremely important, with students preferring immediate debriefing (Miller, Nichols, & Beeken, 2000; O’Connor, Albert, & Thomas, 1999) provided by academic staff present during the simulation (Lasater, 2007; Miller et al., 2000; Weis & Guyton-Simmons, 1998). Debriefing should facilitate reconstruction of real-time representations of students’ interactions and build on existing knowledge to form mental representations of clinical problems (Aronson, Roas, Anfinson, & Light, 1997; Jones, 2002).
High-fidelity simulation is one teaching and learning strategy to ensure students are exposed to a range of clinical situations that they may not experience in their undergraduate clinical placements but may face after graduation.
The aim of the third-year clinical course, consisting of tutorials, clinical laboratory sessions, and 25 days of clinical practice, is to assist students in the development of clinical reasoning. A case-based approach is used to explore the care required for patients with complex health care needs. Each case is explored during a 3-week period, with the acuity of the simulated patient and the complexity of care required increasing each week.
Scenarios were developed using the following guidelines:
- Teaching and learning philosophy and concepts were consistent in all of the scenarios.
- Signs and symptoms were clearly descriptive of a particular clinical situation (Nosofsky & Palmeri, 1997).
- Scenarios progressed in real-time sequence but at a much faster pace than in the actual clinical setting.
- Patients’ responses were clearly identifiable and consistent with student actions.
- Cues increased in complexity as the scenario progressed.
- Appropriate inclusion of visual, auditory, written, olfactory, and kinesthetic cues.
- Cues increased in intensity to accommodate students who failed to identify initial low-intensity cues.
- Student response and actions were required at several levels.
- Students were required to demonstrate psychomotor skills, teamwork, communication (written and verbal), and reasoning.
- Students were required to collaborate among themselves as well as with RNs and other health professionals.
- Inclusion of legal and ethical considerations.
Students were prepared for simulation through interaction with online materials and a hands-on orientation session. Time was scheduled for 300 students (in small groups of 3 to 4 students) to have three direct interactions with the simulated patient for a maximum period of 45 minutes including debriefing.
The high-fidelity simulations addressed management of a patient with chest pain (scenario 1), management of a patient with hypovolemia postsurgery (scenario 2), and management of a patient with a pneumothorax (scenario 3). Students were exposed to the full case including accessing case notes and bed notes prior to and throughout the simulation.
The aims of each of the high-fidelity scenarios (Table 1) were provided to the simulation operator and faculty but not to students. This is consistent with course and clinical aims for students to analyze patient data to identify knowledge and skills required to care for patients, and to use mental rehearsal strategies to mentally prepare to identify and respond to any possible complications. All simulations possessed appropriate visual, auditory, olfactory, kinesthetic, and written cues. A faculty member served as an RN for students to consult throughout the simulation.
Table 1: Objectives of the Three High-Fidelity Scenarios
The simulation commenced immediately after patient handover. Students were expected to review case notes and analyze and interpret the pattern and trend of patient data prior to interacting with the patient. Students were provided with 15 to 20 minutes for interacting with the simulated patient, followed immediately by 15 to 20 minutes of debriefing by the faculty member who acted as the RN during the simulation.
Debriefing was based on students’ reconstruction and perceptions of the processes and the knowledge they used or should have accessed throughout the scenario. In debriefing, students reflected on interactions and interventions, priority of interventions, ethical and legal considerations, individual and team management, and the link between the associated pathophysiology, pharmacology, or rationale for care.
The aim of this evaluative study was to evaluate nursing students’ perceptions of their experiences with three high-fidelity simulations in a clinical nursing course. The opportunistic sample included all third-year students (N = 300) enrolled in a clinical nursing course. The sample size for the three simulations varied (n = 297 for scenario 1, n = 271 for scenario 2, and n = 250 for scenario 3).
After the debriefing, students were asked to anonymously complete an evaluation form. The evaluation form included 11 standardized questions rated on a 5-point Likert-type scale ranging from 1 (strongly disagree) to 5 (strongly agree) and 3 open-ended questions (Table 2).
Table 2: Questions Included on the Evaluation Form
Data were analyzed using SPSS software. Krueger’s (1994) framework analysis was used to analyze qualitative data generated from the three open-ended questions (Rabiee, 2004).
Findings for all three scenarios are discussed together under each question as the results for the scenarios were similar (Table 3). Findings from the qualitative data are reported with the quantitative findings because the students used the open-ended questions to further clarify questionnaire responses as shown by the themes identified in the analysis of qualitative data (Table 4).
Table 3: Percentage of Students Who Agreed or Strongly Agreed with Evaluation Questions
Table 4: Key Themes Generated from the Analysis of Qualitative Data
Interacting with Simman
More than 90% of students enjoyed working with SimMan in all three scenarios (question 1). Their comments reflected an enthusiasm for working with SimMan, a desire for more scenarios, and the enjoyment of working in a small group.
The majority of students (mean = 94.7%) reported that their attention was maintained throughout the simulation across the three scenarios (question 2). The need to constantly analyze, interpret, and respond to cues was the main feature of the simulation attributed by students as maintaining their attention. This was reflected in students’ comments such as “thinking of the order things need to be done in,” “that we are understanding what we are doing,” and “makes you think more and be quicker in decision making.”
All three scenarios were rated by the majority of students (mean = 92.4%) as possessing an appropriate level of challenge (question 3). Students’ comments revealed that the simulation challenged them “to look at the patient completely in all areas, to assess the patient and tend to his needs,” and “to always check drains, drips, etc. at beginning of shift.”
Students who disagreed (mean = 2.4%) or were uncertain (mean = 4.8%) about the appropriateness of the level of challenge fell into two subgroups: those who desired a higher level of challenge and those who felt the scenario was a little too complex. This was highlighted by student comments such as “a need for more of a challenge,” “more complications so we get every possible situation and can configure a rationale” and “feel the pressure of a real situation.”
Students (mean = 94%) perceived a close relationship between the simulation and theoretical course content (question 4). The majority of students (mean = 95%) rated the simulation as being useful to what they were learning in the course (question 6). Comments demonstrated students’ recognition of the relevance and usefulness of the scenarios to their current learning. Comments illustrating this were “being able to see the link between the scenario in the tutorial and what to do at what stage and why” and “bringing theory to practice and able to visualize the effect of symptoms to a patient and outcomes.”
Students often commented on the learning of a particular concept (e.g., fluid and electrolyte balance) or particular skills as well as the process of providing care to a patient in a particular scenario. Students commented that the high-fidelity simulations increased the reality of the theory of the course. This was reflected in students’ comments such as “seeing everything we read in the scenario come to life and be applied in a real-life situation,” and “it draws together the knowledge you have and helps you put it all together and make it relevant.”
In addition, students confirmed their understanding of the importance of the nursing role. One student commented, “Often problems will respond to nursing actions, therefore [you] need to do something before calling a doctor.”
A majority of students reported that they felt lost at some time during all of the simulations (question 7); a mean of 31.5% agreed and 18.2% strongly agreed with this statement. Students’ comments suggested these feelings of confusion were transient and occurred at a particular stage in the patient’s clinical progression rather than throughout the scenario. One student’s comment reflected the process of reasoning during the simulation; the student noted feeling “confusion as to what was actually wrong with the patient.... There is a lot to cover in a short amount of time, so I got confused in some parts.”
Most of the students (mean = 97%) across the three scenarios indicated close links between the scenarios and the usefulness of knowledge gained to clinical practice (question 8). The qualitative findings also confirmed the relationship among the simulations and students’ ability to apply this knowledge to nursing care. For example, one student related the scenario to understanding a recent clinical experience, stating “I recently had a patient in a similar situation, and it is good to have an understanding of why things were/are done.”
Other students commented on the replication of the pressure experienced in the clinical setting (“turns the situation into something that could actually happen in the hospitals”), the importance of teamwork (“being able to talk to other students when problems arise”), the realism of the simulation (“quite realistic, good to see the changing dynamics related to our nursing actions”), and learning through seeing a patient’s response to their actions (“bringing theory to practice and able to visualize the effect on symptoms and patient outcomes”). Students’ perceptions were that high-fidelity simulation assisted them in understanding nursing care and rationales for clinical intervention. This was highlighted by comments such as “helps me understand what would be required of me if these situations happened on the ward,” “I now understand better about different IV fluids,” and “being able to see the link between the scenario in the tutorial and what to do at what stage and why.”
Students’ comments on caring for the patient in scenario 3 reaffirmed the dynamic focus of the scenarios in incorporating activities to facilitate development of students’ knowledge, assessment, psychomotor skills, and reasoning. Comments included: “how to care for a patient with a tension pneumothorax,” “what the signs and symptoms of a tension pneumothorax are,” “what to check for in respect to pain, air entry…and how to treat the problem,” and “how a tension pneumothorax develops and how it resolves.”
Students’ responses on the value of debriefing were positive. More than 95% agreed that feedback sessions confirmed management of patients’ problems (question 9), helped to develop rationale for actions (question 10), and assisted in understanding reasons for medication and fluid management (question 11). Students commented that debriefing was “useful and learned many things that were still unclear after the seminar,” “good to be able to reflect on actions and understand things more,” “explained everything we needed to know about this scenario,” and “well presented in a nonthreatening environment.” Many students stated they would have appreciated more time in debriefing to fully explore concepts central to the scenario.
Areas of Simulation Requiring Improvement
Fewer students commented on areas that required improvement. Those students who did comment indicated that they desired more time for familiarization with SimMan and its capabilities, more simulations, more complex simulations, more complications, doctor-nurse team interactions, smaller groups, and greater team-work. In addition, students indicated that they would have liked the simulated patient to have the voice and appearance of the patient’s particular gender for the individual scenarios.
Faculty’s efforts in overcoming the logistical challenges of implementing high-fidelity simulation are rewarded by students’ positive evaluations. This study demonstrated the need to maintain a high degree of fidelity to actual clinical situations. This required careful planning with a team of clinicians and faculty to ensure that visual, auditory, written, olfactory, and kinesthetic cues were appropriately embedded in the scenario.
The tight link maintained among the aims, content, and philosophy of the course and simulations possessed the potential to increase and consolidate student learning and increase their perceptions of the application of this learning to practice. Simulation is an important inclusion in the curriculum, but ongoing staff development and the construction implementation of high-fidelity scenarios must take into account the year level of students and the congruency of scenarios to both the curriculum and the course, and also adhere to a set of principles to ensure the incorporation of strategies relevant to multiple styles of learning and fidelity with current clinical practice.
Enjoyment is an important concept as previous results demonstrated a link between student enjoyment of learning and retention and reinforcement of knowledge (Herrman, 2002; Skiba, 1997). Similar to the findings of Lasater (2007), Herrman (2002), and Skiba (1997), our findings indicated students enjoyed working with SimMan, and increased familiarity with working with the high-fidelity simulator did not change students’ degree of enjoyment. The finding that students’ attention was maintained throughout all of the scenarios perhaps attests to the degree of complexity and the accurate reproduction of ongoing changes in the patient’s clinical progression in response to students’ actions.
The large percentage of students’ transient experiences of confusion in all three of the scenarios may suggest that the level of complexity was too high. However, because more than 90% of students thought the scenarios presented an appropriate level of challenge, confusion was not seen as a negative aspect of a simulation but expected in light of students’ developing level of reasoning and unfamiliarity with different clinical situations. Inclusion of specific objectives as advised by many authors (Issenberg et al., 2005; Jeffries, 2007) may have decreased students’ level of confusion but would have negatively impacted on the value of students’ personal exploration of data in identifying and responding to a problem and decreased the degree of fidelity.
Not informing students of the specific objectives of a scenario also ensures the maintenance of fidelity with students’ roles in clinical settings. In clinical situations, third-year students are expected to “know their patients” and to identify and mentally rehearse their response to possible complications prior to patient interaction. In contrast to findings by Larew, Lessans, Spunt, Foster, and Covington (2006), students in our study did not feel overwhelmed and anxious throughout any of the scenarios because of the perceived complexity of the cases.
Students’ perception of a close relationship of scenarios to learning in the clinical course attested to the involvement of the faculty in developing and validating the scenarios; the adherence to the philosophy of learning; and the careful selection of cues, possible student responses, and nursing actions. In addition, our finding that more than 95% of students thought knowledge gained in the simulations was transferable to the clinical setting is in direct contrast to the findings of Feingold et al. (2004). The findings of clinical relevance may be attributed to the close integration of the simulation to the learning approach and concepts being studied simultaneously by students with concurrent clinical placement of 2 days per week.
Concurrent clinical placement does not, however, account for the positive evaluations obtained from students not on placement. Although clinical placements have a significant influence on learning, the depth of learning can also be superficial without a focus on refection (Murphy, 2004; Tanner, 2006). The benefits of simulation on the other hand are enhanced by the immediacy of debriefing and therefore reflection.
High-fidelity simulation not only ensures that learning is student focused but also role models the reflective process and the need to identify rationale for practice that is transferable between academic and clinical environments. Students’ comments highlighted the role high-fidelity simulation has in ensuring exposure of all students to concepts and situations not available in all clinical placements (Andrews & Jones, 1996; Shepherd, Kelly, Skene, & White, 2007). This study demonstrated the benefits of embedding essential features of a clinical situation into the simulation and the learning acquired by students from the elicitation of visual and verbal cues and by students observing the patient’s response to their actions.
Collaboration is an integral component of clinical practice (Hamman, 2004). Even though students worked with the same small group of students in tutorials and clinical laboratories, initial collaboration was tentative, and it was not really until the final simulation that this became natural and nonthreatening. Students in this study identified the need to incorporate more doctor-nurse collaboration in the scenario, but they also identified the benefits of student-to-student collaboration. Students also recognized the importance of implementing relevant nursing activities prior to collaboration or referral of patient care to a physician.
Debriefing is an important component of high-fidelity simulation as it aids in error correction, reflection, and identification of clinical problems; promotes insightfulness (Kuiper & Pesut, 2004); and is necessary for identification of pattern recognition and clinical decision making (Ruth-Sahd, 2003). Immediate debriefing by the faculty present throughout the simulation ensured a focus on students’ critical reflection on their actions in response to changes in the patient’s clinical status. Students’ collaborative identification of the knowledge and skills used, the appropriate sequence of their response, and ongoing learning needs facilitated student-directed learning. The debriefing session was seen as highly beneficial in clarifying theory, developing rationale, and preparing students for practice.
It is essential to examine students’ perceptions of the aim of debriefing prior to extending debriefing time. Students’ desire for more than 15 to 20 minutes in debriefing is congruent with previous findings (Savoldelli et al., 2006). Ultimately, gaps still exist in research on the process, time required, and learning associated with debriefing, and more research is required prior to accepting increased time as the answer to students’ evaluation.
High-fidelity simulation must be incorporated into the curriculum and not seen as a stand-alone educational tool. Each simulation must possess the ability to assist in nursing skill acquisition, retention of knowledge, transference of theory to clinical practice, development of self-confidence, enhanced understanding of rationales of clinical care, and development of clinical reasoning.
Research is required to further validate the relationship between the use of high-fidelity simulation and the development of students’ clinical reasoning skills, to examine the relationship between confusion (i.e., “feeling lost”) and student learning, and to further explore the benefits of debriefing. The current advice for the provision of specific and detailed learning objectives for a simulation designed to mirror the role of nurses in the clinical environment needs to be debated by nurse educators.
Nurse educators continue to strive to enhance nursing students’ clinical reasoning, transference of theory to clinical practice, skill acquisition, and critical thinking. It is well known that clinical placements are short and competition for placements is high. Students may therefore lack authentic clinical exposure to many common conditions, skills, and knowledge.
High-fidelity simulation in nursing education is not the only solution, but when incorporated into curriculum, it can become a powerful bridge between theory and practice by enhancing students’ cognitive, associative, and autonomous skills. The future of high-fidelity simulations in clinical education is grandiose in scale, and one can only become excited at the prospect of its future with technological advances, more awareness about simulations, and more research to support its validity and reliability.
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Objectives of the Three High-Fidelity Scenarios
|Scenario 1||Scenario 2||Scenario 3|
Identify signs and symptoms of angina
Articulate the cause for signs and symptoms of angina
Appropriately respond to signs and symptoms of angina
Articulate a rationale for the management of angina
Monitor patient’s response to management
Respond to side effects of GTN
Provide a rationale for the response to side effects of GTN
Demonstrate an ability to reflect on practice and a plan for how to improve practice and knowledge
Monitor, evaluate, and interpret the pattern and trend in signs and symptoms
Identify signs and symptoms of hypovolemia
Articulate the probable pathophysiology of hypovolemia in this case and use signs and symptoms to prove this
Implement initial nursing management for hypovolemia
Articulate rationale for initial management
Implement medically prescribed management
Articulate rationale for the use of positioning, crystalloids, or colloids
Identify criteria used in the evaluation of patient’s response to crystalloids and colloids
Identify, interpret, and understand reasons for changes in patterns and trends of patient data in a tension pneumothorax
Undertake an organized assessment for a patient with a pneumothorax who has a chest tube inserted attached to a UWSD
Develop a format for troubleshooting causes of cessation of swinging of fluid in a chest tube attached to UWSD
Implement appropriate actions for a tension pneumothorax and evaluate the effectiveness of these outcomes
Develop an understanding of the reasons for the development of a pneumothorax, hemopneumothorax, and tension pneumothorax
Questions Included on the Evaluation Form
|Questions Rated Using a 5-Point Likert Scalea|
I enjoyed working with SimMan®
My attention was maintained throughout the simulation
Simulation provided and maintained an appropriate level of challenge
Simulation was closely related to the learning in the case explored during the 3 weeks
Session aroused curiosity, provided me with the opportunity to explore different concepts
Session relevant as it showed the usefulness of what I was learning
At times I felt lost as we worked through the simulation
The knowledge I gained from this simulation could be used in nursing care
Feedback sessions: helpful in confirming management of the patient’s problem
Feedback sessions: helpful in developing rationale for action and responses to patient
Feedback sessions: helpful in understanding actions of medications
|What were the most positive aspects of working with SimMan?|
|What areas of working with SimMan do you feel need to be improved?|
|What did you learn from being involved with this patient?|
Percentage of Students Who Agreed or Strongly Agreed with Evaluation Questions
|Question Number||% of Students Who Agreed or Strongly Agreed|
|Scenario 1||Scenario 2||Scenario 3|
|2. Maintain attention||96||94.9||93.2|
|4. Relate to teaching and learning||96.9||95.9||93.2|
|7. Feeling lost||54.1||49.7||45.9|
|8. Usefulness and relevance||96.9||99.8||94.7|
|9. Feedback: confirm management||94.2||96.2||93.7|
|10. Feedback: rationale||95.2||95.6||94.1|
|11. Feedback: understanding actions of medications||92.1||92.9||NA|
Key Themes Generated from the Analysis of Qualitative Data
|Positive Aspects of Working with SimMan®||Areas for Improvement||What Was Learned|
|Realistic/real||Enthusiasm of group||Opportunity to learn|
|Knowledge||Props usage||Good for knowledge building and use|
|Link theory to topic and practice||Less input from lecturer||Explained well|
|Role||Theory and knowledge||Spend more time on debriefing|
|Stimulated thinking||Level of difficulty|
|Evaluation of treatment|