Ms. Leonard is Simulation Project Co-coordinator and Ms. Shuhaibar is Clinical Skills Practice Instructor, Centre for Simulation-Based Learning, and Ms. Chen is Assistant Professor, School of Nursing, McMaster University, Hamilton, Ontario, Canada.
The authors have no financial or proprietary interest in the materials presented herein.
Address correspondence to Ruth Chen, MSN, RN, Assistant Professor, School of Nursing, McMaster University, 1200 Main Street West, HSC 2J34H, Hamilton, Ontario, Canada L8N 3Z5; e-mail: firstname.lastname@example.org.
High-fidelity simulation has been integrated into health professional programs in response to the shifting needs within clinical practice and educational settings. In simulation, the students are presented with a clinical situation similar to what they would encounter in an actual clinical environment, and they receive feedback on their performance following the simulation (Issenberg, McGaghie, Petrusa, Gorden, & Scalese, 2005). Simulation is used to help learners develop technical nursing skills and problem solving abilities (Reilly & Spratt, 2007). It also offers immediate feedback on performance and helps increase confidence as students transition from academia to clinical practice (Goldenberg, Andrusyszyn, & Iwasiw, 2005).
Several published articles have discussed students’ simulation experiences when learning either alongside classmates within the same year of the program (Feingold, Calaluce, & Kallen, 2004; Goldenberg et al., 2005; Lasater, 2007; Reilly & Spratt, 2007) or within interprofessional teams (Paige et al., 2007). However, the benefits and unique learning opportunities resulting from an intraprofessional approach (where multiple levels of nursing students are grouped together within one simulation experience) have not been explored; therefore, the goal of this project was to explore nursing students’ perceptions of learning within an intraprofessional simulation context.
One adult scenario and one pediatric scenario, which involved Laerdal™ SimBaby and SimMan simulators (Laerdal Medical, Stavanger, Norway), were developed and used for the simulations. The scenarios were common patient cardiac (adult) and respiratory (pediatric) situations, involving multiple layers of clinical complexity. The simulations were voluntary. The students could choose between pediatric, adult, or both scenarios, with a maximum of 5 students per experience.
The educational experience attracted nursing students from all levels (first through fourth years) of the undergraduate BSN program at McMaster University, and students provided consent to participate. Because all collected data were anonymous, age and gender were not reported. However, participants were well distributed across all program levels. Each simulation ran for 15 to 30 minutes, and debriefing sessions followed each simulation.
Rogers’ (1971) approach to facilitation and Banning’s (2008) think aloud approach to learning served as the theoretical underpinnings guiding the simulation exercises. The students were instructed to work within their scope of practice based on their particular level of education in the nursing program. After the simulation debriefing, participants were given a satisfaction survey and were asked to provide written responses to 10 open-ended questions (Table). For example, students were asked to share their perspectives about working within an intraprofessional team compared with an interprofessional team, and what they did and did not find helpful or valuable from participating in the simulation experience.
Table: Satisfaction Survey
Forty-eight undergraduate nursing students participated in this innovative educational experience. The response rate was 100% for student participants. All data obtained from the students remained confidential and anonymous and were used only for program evaluation purposes. All written responses from the questionnaires were transcribed; each investigator independently reviewed all participant responses and grouped responses according to key themes emerging from the data. The investigators arrived at a consensus regarding the key themes after multiple discussions and reviews of the transcribed responses. Member checking around the key themes identified was performed with 4 participants.
From this iterative process of data analysis, three key themes emerged from the student responses: role recognition and differentiation, adaptation to team environment, and professional solidarity.
Role Recognition and Differentiation
Participating in the simulations offered the students an opportunity to recognize their unique strengths and their ability to contribute to nursing care based on their particular nursing education level. For example, first-year students focused on their communication and basic assessment skills; second-year students recognized they had confidence in initiating fuller assessments due to their increased clinical practice exposure; third-year students found that they were able to refine their organizational skills and felt more comfortable with decision making and implementing nursing interventions (e.g., medication administration); and fourth-year students exercised a greater leadership role, focusing on delegation of responsibilities and overseeing the overall nursing care of the simulator “patient.”
The students identified their unique roles based on how they felt they were best able to contribute to the scenarios. A second-year student expressed involvement in the simulation as, “I [focused on] the ABC’s [assessment of airway, breathing, circulation].” A third-year student used “past knowledge from clinical as well as past classes [Pathophysiology]” and felt that the simulation contributed to the students’ learning and confidence. A fourth-year student felt that he “[had more] comprehensive knowledge and critical thinking. I know what the diagnosis, etiology, is and know how to solve the problem; I have the nursing skills to implement treatment/interventions.”
Adaptation to Team Environment
Perceptions of the team environment during the simulation were considered positive. The students observed that team work was “Challenging. A little anxious at first but environment and communication with team/peers really helped enhance [the] experience.” Students also reported feeling confident to discuss with team members the interventions that occurred while the scenario progressed. “Being level one [a first-year student], I was able to ask questions to the scenario’s participants that were actually realistic.” Other students felt “comfortable [and that] it was more reassuring to have peer support,” and that “the team was able to work together and help with decision making.” In addition, students expressed feeling “increased comfort and confidence with delegating tasks, reporting clinical findings and functioning effectively with others” as a result of the intra-professional team dynamics brought forth in the simulation.
Because the students worked together as an intraprofessional team, it became evident that they were able to support each other as students within the same health professional program regardless of their varying levels of knowledge and clinical exposure. One key theme identified in the participant responses was the students’ sense of professional solidarity arising from the intraprofessional simulation experience. The students felt that the “nurse-only” simulations, as opposed to interdisciplinary simulations, added to their learning because they felt more comfortable learning with students within the same program. The students expressed that they were “able to use a team of nurses to problem-solve” and that they “appreciated the ‘nurse only’ [intraprofessional approach to] simulation; interdisciplinary would have allowed [sic] nurses to stand in [the] background.”
Additional statements expressed how the students felt during the simulation experience:
- I enjoyed [that] just the nurses at this time showed us [how] to ‘take charge’ and think things through.
- I enjoyed being with only nurses and their roles in direct patient care. If other disciplines were involved the direction of care and assessments would not be the same—nursing orientated.
- I believe that the nurse-only approach is ideal at this time. It solidifies a practice base that allows the exploration of the nursing scope of practice.
- I enjoy the nurse only situation at this level. It allows us to concentrate on our level of learning at the moment.
- In reality, it is often nurse only going on. I feel that having a nurse only simulation was very beneficial due to the fact that all team members were able to focus from one scope of practice.
Third-year students expressed their excitement to advance to the next level of nursing practice, whereas fourth-year students appreciated the opportunity to coach and support third-year students. Students appreciated working through the simulation scenario with their peers and felt the intraprofessional atmosphere promoted a sense of solidarity and enthusiasm for the nursing profession.
The purpose of this educational experience was to explore undergraduate nursing students’ perspectives of participating in an intraprofessional simulation. From the key themes identified, it was evident that the intraprofessional approach to education offered advantages different from training students either exclusively with their peers within the same academic year or within interprofessional teams. Although these two approaches are valuable, intraprofessional simulation activities offer additional learning opportunities that achieve complementary educational objectives. Furthermore, the unique benefits of intraprofessional simulation have not been well articulated in the literature.
It was apparent that students not only appreciated how they could enact the nursing role based on their current level of education, but also that they were able to see what students from other years in the program could contribute (role recognition and differentiation). It helped the student to see how scaffolding of learning occurs within the program.
In addition, students felt that the intraprofessional simulation helped them adapt to a team environment, a context in ways analogous to patient care settings where staff nurses of varying levels of experience must work cohesively, particularly with unstable patients or during critical events. Finally, allowing students to work alongside those in other years of the nursing program enhanced the students’ sense of professional solidarity.
Implicit in this intraprofessional simulation study was not only the desire to explore the value of peer coaching in general as pedagogy for nursing education, but also more specifically as a relevant and useful approach in simulation-based education. Although peer coaching is not unique to nursing (Aviram, Ophir, Raviv, & Shiloah, 1998), it has not, to our knowledge, been explored in the context of high-fidelity simulation involving intraprofessional teams. Because these clinical scenarios were presented in a simulation environment versus an actual clinical setting, the students were videorecorded and the recordings were reviewed during the debriefing sessions.
The debriefings allowed students to receive feedback from their peers and from the clinical faculty and, given the intraprofessional environment, permitted the students to share their perspectives of the simulation experience from their distinct year-specific vantage points. Fourth-year students were able to provide guidance and mentorship to the third-year students without assuming a formal teaching or evaluation role, a practice that has been documented in hospital-based clinical education settings (Broscious & Saunders, 2001).
However, it is important to note that fourth-year students also depended on the involvement of third-year students when providing nursing care in the simulation. Third-year students were active participants in the simulation scenarios even if their knowledge base and clinical experiences were more limited than that of the fourth-year students. As Green and Puetzer (2002) recognized:
The implementation of a structured mentoring program recognizes the need to develop and maintain relationships between the new and the experienced nurse. Academia prepares nurses with the basic understanding of the science that is patient care delivery, and therefore, is the prime site for mentoring to begin.
An encouraging finding tied to the theme of professional solidarity was that the high-fidelity simulations provided a framework for professional development; the students expressed their excitement to advance to the next level of nursing practice and into their future professional roles as a result of having participated the intraprofessional simulation. Although students appreciated simulations that involved only nursing students, they recognized the need for further professional development within interprofessional teams and desired these simulation experiences in the final year of the nursing program.
For some students, participation in this study reaped other unexpected rewards. One first-year student stated that “the opportunity to be involved in the intraprofessional high-fidelity simulations kept me from leaving nursing because it allowed me to see how my nursing education and skills acquisition would progress throughout the program.” Another student expressed a desire to become involved in research related to simulation and intraprofessional teams; the following year, this student took a position as a learning assistant so she could mentor nursing students in other years of the program. These anecdotal findings suggest that providing students with opportunities to engage with those in other years of the program facilitates student engagement and could possibly play a role in the recruitment and retention of nurses in the health care system.
The results of this study suggest that intraprofessional team training with high-fidelity simulation provides unique learning opportunities for undergraduate nursing students. Key themes of role recognition and differentiation, adaptation to the team environment, and professional solidarity were identified from student responses. The findings are encouraging and support further investigation of the use of intraprofessional teams in high-fidelity simulation for students in health professional programs.
- Aviram, M., Ophir, R., Raviv, D. & Shiloah, M. (1998). Experiential learning of clinical skills by beginning nursing students: “Coaching” project by fourth-year student interns. Journal of Nursing Education, 37, 228–231
- Banning, M. (2008). The think aloud approach as an educational tool to develop and assess clinical reasoning in undergraduate students. Nurse Education Today, 28, 8–14. doi:10.1016/j.nedt.2007.02.001 [CrossRef]
- Broscious, S.K. & Saunders, D.J. (2001). Clinical strategies: Peer coaching. Nurse Educator, 26, 212–214. doi:10.1097/00006223-200109000-00009 [CrossRef]
- Feingold, C.E., Calaluce, M. & Kallen, M. (2004). Computerized patient model and simulated clinical experiences: Evaluation with baccalaureate nursing students. Journal of Nursing Education, 43, 156–163.
- Goldenberg, D., Andrusyszyn, M. & Iwasiw, C. (2005). The effect of classroom simulation on nursing students’ self-efficacy related to health teaching. Journal of Nursing Education, 44, 310–314.
- Green, M.T. & Puetzer, M. (2002). The value of mentoring: A strategic approach to retention and recruitment. Journal of Nursing Care Quality, 17(1), 63–70.
- Issenberg, S.B., McGaghie, W.C., Petrusa, E.R., Gorden, D.L. & Scalese, R.J. (2005). Features and uses of high-fidelity medical simulations that lead to effective learning: A BEME systematic review. Medical Teacher, 27, 10–28. doi:10.1080/01421590500046924 [CrossRef]
- Lasater, K. (2007). High-fidelity simulation and the development of clinical judgment: Students’ experiences. Journal of Nursing Education, 46, 269–276.
- Paige, J., Kozmenko, V., Morgan, B., Howell, D.S., Chauvin, S. & Hilton, C. et al. (2007). From the flight deck to the operating room: An initial pilot study of the feasibility and potential impact of true interdisciplinary team training using high-fidelity simulation. Journal of Surgical Education, 64, 369–377. doi:10.1016/j.jsurg.2007.03.009 [CrossRef]
- Reilly, A. & Spratt, C. (2007). The perceptions of undergraduate student nurses of high-fidelity simulation-based learning: A case report from the University of Tasmania. Nurse Education Today, 27, 542–550. doi:10.1016/j.nedt.2006.08.015 [CrossRef]
- Rogers, C. (1971). Carl Rogers describes his way of facilitating encounter groups. American Journal of Nursing, 71, 275–279. doi:10.2307/3421801 [CrossRef]
How was the high-fidelity scenario helpful or not helpful in reinforcing your knowledge base?
How was the high-fidelity scenario effective or not effective in allowing a safe environment to practice?
Did you appreciate the scenario being a nursing-only simulation, or would you prefer an interdisciplinary approach at this time? In the future? Why?
After participating in the high-fidelity scenario, would you feel more confident in a similar situation in the clinical environment?
Did the scenario allow you to use your critical thinking and decision making skills? How?
Did you find it challenging or comfortable working in a team situation? How well did you think the team communicated? Please explain.
What did you think your strengths were?
What did you think your limitations were?
What did you find most valuable participating in this high-fidelity scenario?
What would you like to see done differently in the next high-fidelity scenario?