Journal of Nursing Education

Major Articles 

Transformative Learning as a Context for Human Patient Simulation

Brian Parker, BScN, RN, RPN; Florence Myrick, PhD, RN


Nurse educators are charged with the responsibility of empowering novice nurses to become autonomous thinkers with the capacity to cope with the many challenges of modern day practice. Human patient simulation is a powerful technology-based educational tool ideally suited for the application of emancipatory pedagogies that aid in the transformation of individual meaning schemes. Transformative learning theory provides educators with the tools to empower students to challenge their preconceived beliefs, assumptions, and values and socialize them appropriately to thrive in modern day clinical practice. The purpose of this article is to critically analyze the role of clinical scenarios using human patient simulation to promote transformative learning events in undergraduate nursing education. The authors focus on the role of debriefing in the promotion of the critical reflection and social discourse that is integral to the learning process and the implementation of scenarios that provide students with disorientating dilemmas for perspective transformation.


Nurse educators are charged with the responsibility of empowering novice nurses to become autonomous thinkers with the capacity to cope with the many challenges of modern day practice. Human patient simulation is a powerful technology-based educational tool ideally suited for the application of emancipatory pedagogies that aid in the transformation of individual meaning schemes. Transformative learning theory provides educators with the tools to empower students to challenge their preconceived beliefs, assumptions, and values and socialize them appropriately to thrive in modern day clinical practice. The purpose of this article is to critically analyze the role of clinical scenarios using human patient simulation to promote transformative learning events in undergraduate nursing education. The authors focus on the role of debriefing in the promotion of the critical reflection and social discourse that is integral to the learning process and the implementation of scenarios that provide students with disorientating dilemmas for perspective transformation.

Mr. Parker is a PhD candidate, Faculty of Nursing, University of Alberta, and Faculty, Faculty of Health and Community Studies, Grant MacEwan University, and Dr. Myrick is Professor and Associate Dean, Teaching Learning, Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada.

The authors have no financial or proprietary interest in the materials presented herein.

Address correspondence to Brian Parker, BScN, RN, RPN, Faculty of Nursing, 3rd Floor Clinical Sciences Building, University of Alberta, Edmonton, Alberta, Canada T6G 2G3; e-mail:

Received: July 21, 2009
Accepted: September 24, 2009
Posted Online: June 03, 2010

Human patient simulation (HPS) has been adopted in nursing education programs because of its ability to provide undergraduate baccalaureate nursing students with immersive, reality-based clinical experiences (Bearnson & Wiker, 2005; Yeager et al., 2004). Simulated clinical scenarios are developed to use the technology inherent in the high-fidelity simulated manikins designed to mimic human physiological responses to illnesses, trauma, and nursing interventions (Bearnson & Wiker, 2005; Yeager et al., 2004). Although a growing body of evidence has validated the use of this technology-based learning tool, further research and critical analysis are needed to promote the most effective application of HPS in nursing education (Day-Black & Watties-Daniels, 2006; Mallow & Gilji, 1999).

As Dewey (1938) noted, without proper reflection on our underlying values and beliefs about teaching and learning, we leave the education of our students to the whim of every educational trend that comes our way. Thus, we need to be diligent in analyzing and contextualizing the role that educational theory and philosophy play in our pedagogical practices to understand the effects of the adaptation of learning tools such as HPS on our students and ultimately on their professional practice (Shovein, Huston, Fox, & Damazo, 2005).

One of the responsibilities of nursing education is to help adult learners develop knowledge applicable to practice. As educators, we are charged with the challenge of socializing students into the profession of nursing and providing them with opportunities to acquire the requisite knowledge and cognitive processes to practice in an increasingly complex health care environment (Brennan & McSherry, 2007; Lindeman, 2000). To guide students in this cognitive transformation, it is incumbent on educators to continuously critique the curriculum and the educational practices that contribute to student socialization and their knowledge development and skills in preparation for patient care. Human patient simulation is a powerful tool, but it is only a tool (Shovein et al., 2005).

Cranton and King (2003) noted that both knowledge and knowledge of teaching can be emancipatory. In other words, if HPS is deemed to be a valid tool in nursing education, it is important that we critically analyze our educational practices and reflect on not only how they work, but also why they work (Cranton, 1996). If a goal is to transform our students into professionals with the cognitive ability, skills, and knowledge to practice in today’s health care environment, it is important that we assess the tools we use to assist students in this transformation. Human patient simulation is one such tool that potentially provides students with complex learning environments that can reflect a reality-based clinical environment and lead to transformative learning when properly designed.

The purpose of this article is to critically analyze the role of HPS-based clinical scenarios in contributing to transformative learning for nursing students who are preparing to enter practice in today’s health care setting. From this perspective, the authors review transformative learning theory as espoused by Mezirow (1994, 1995) and discuss the basic process of transformative learning and the role that critical reflection plays in the promotion of autonomous thinking in adult learners. This process is followed by a discussion regarding the role of simulation in promoting transformative learning in our pedagogical practices. In particular, this article explores the importance of the debriefing phase of the simulation learning experience in encouraging critical reflection, a key consideration in adult-learning and transformative-learning theory.

High-Fidelity Human Patient Simulation

Because of the various definitions of HPS in health care literature, it is important to define high-fidelity HPS as it is conceptualized throughout this article. Bearnson and Wiker (2005) described HPS as a computer-controlled manikin designed to provide practitioners with human-like responses to nursing interventions, such as medication administration, catheterization, and oxygen therapy. The manikin is designed to appear human and the functions are controlled by the instructor via a computer, which allows the instructor to direct scenarios that mimic illness and trauma via interactive physiological systems, such as cardiovascular, respiratory, and neurological. High-fidelity implies that these manikins are technologically advanced and able to speak, breathe, and perspire (Medical Education Technologies, Inc., 2004). With properly designed surroundings that replicate a hospital room, the goal is to provide students with a reality-based immersive clinical experience (Yeager et al., 2004).

Prior to engagement in the scenario, some form of orientation usually occurs (Rhodes & Curran, 2005). This process may include providing students with specific learning objectives to increase their familiarity with the physiological conditions encountered in the scenario, time to spend with the HPS manikin to decrease the stress of interacting with this high-fidelity educational tool, or both. Students are engaged in a predesigned clinical scenario in groups often comprised of four to five students who assume different roles in the treatment team (Rhodes & Curran, 2005). Examples of possible treatment team roles include the recorder, the primary nurse, and the alternate care providers (Rhodes & Curran, 2005).

After the scenario is completed, the protocol requires students and a facilitator to engage in a debriefing mode that allows an opportunity to discuss their perceptions of their performance, problem-solve decisions that they have made, and share in a supportive evaluation process, all of which will assist in reinforcing the learning and knowledge development that has occurred (Rhodes & Curran, 2005). Rhodes and Curran (2005) suggested that the faculty member should function primarily as a facilitator throughout the debriefing process. Throughout the simulation learning experience, it is important to ensure the promotion of student autonomy and empowerment, thereby affording them the opportunity to develop knowledge that is relevant to their own perceived learning needs.

Transformative Learning Theory

Transformative learning theory derives from the premise that today’s adult learner needs to develop the ability to become an independent autonomous thinker (Imel, 1998; Mezirow, 1997). The authors contend that an HPS-based clinical scenario, with its constructivist pedagogical underpinnings that foster interpretive, generative learning (Dabbagh & Bannan-Ritland, 2005; Magee, 2006), is ideally suited to promote transformative learning. Mezirow is considered the creator and predominant scholar regarding the theory of transformative learning (Imel, 1998; Whitelaw, Sears, & Campbell, 2004).

Mezirow’s conceptualization of transformative learning theory reflects three central themes: the role of experience, rational discourse, and critical reflection in knowledge development for the adult learner (Imel, 1998). Transformative learning theory has many conceptualizations, but for the purposes of this article the authors focus on transformative learning theory as espoused by Mezirow. This classical version provides a foundation for a critical analysis of the role of HPS-based clinical scenario debriefing in transforming cognitive schema, including beliefs and attitudes that enable the nursing student to function in the complexity of today’s health care context.

Mezirow’s transformative learning theory has developed into “a comprehensive and complex description of how learners construe, validate, and reformulate the meaning of their experience” (Cranton, 1994, p. 22). Cranton and King (2003) noted that the basic concept at the heart of transformative learning is that learners develop their understanding of the world through experiences. They then develop habits of the mind in which they expect that what happened once will invariably happen again (Cranton & King, 2003; Mezirow, 1994). This process is a frame of reference for a particular experience that is developed through an uncritical lens that allows individuals to create values, assumptions, and beliefs about a particular phenomenon with minimal thought or cognitive processing (Cranton & King, 2003).

Mezirow (1994) referred to this frame of reference as a meaning scheme, which includes “constellations of concepts, beliefs, judgments, and feelings which shape a particular interpretation” (p. 223). True learning occurs when individuals are faced with a crisis or major transitional experience, which Mezirow (1995) referred to as a “disorientating dilemma” that challenges and alters their rudimentary frames of reference (p. 50). Although Mezirow noted that, for some, the transformation occurs through a gradual accumulation of related experiences that progressively alter individual meaning schemes, the end result is similar—the transformation of meaning schemes that affect how individuals interpret and interact with the world.

Perspective Transformation

The essence of transformative learning theory is that learners alter their meaning schemes or frames of reference and use their new perspective when they subsequently engage in the world (Whitelaw et al., 2004). Cranton and King (2003) noted that transformative learning occurs when learners confront the disorientating dilemma and critically appraise the previous frame of reference about the phenomenon or experience in question. True constructive learning occurs when this appraisal transforms our perspective or habit of the mind into an alternative way of interacting with the world (Cranton & King, 2003). Mezirow (1994) used the phrase “perspective transformation” (p. 224) to describe the process of changing an individual’s meaning structures or frames of reference in the face of a disorientating dilemma. Mezirow (1991) wrote:

Perspective transformation begins when we encounter experiences, often in an emotionally charged situation that fail to fit our expectations and consequently lack meaning for us, or we encounter an anomaly that cannot be given coherence either by learning within existing schemes or by learning new schemes.

Combined with previous experiences, culture forms the aforementioned frames of reference, which ultimately impact how individuals relate to and interpret the world (Imel, 1998). The effects of culture and society on the development of meaning structures in transformative learning theory reflects a relation to emancipatory and critical pedagogies that philosophers such as Dewey (1916/2005) and Freire (1974/2000) espoused. Both Dewey (1916/2005) and Freire (1974/2000) viewed education as a medium for social change that involves personal evolution and development. Learning has the potential for personal evolution and transformation to push the adult learner to the level of an autonomous and empowered thinker (Imel, 1998; Mezirow, 1995).

During learning, students acquire new information, which they then interpret using their existing meaning structures. This process can transform perspectives into new ways of interpreting phenomenon suddenly or, in some instances, gradually; affect values, beliefs, and previously held assumptions; and lead to true transformative learning (Imel, 1998). Mezirow (1978, 1994) believed that perspective transformation occurred through a rational process that begins with an experience of the disorientating dilemma followed by self-examination and assessment of assumptions, connection with others who are experiencing similar transformations, discovery of new ways of interpreting meaning, the creation and trial of a new plan of action, and the building of confidence toward reintegration into the world reinforced with a new perspective (Cranton, 1994; Imel, 1998; Mezirow, 1995). This process leads to knowledge acquisition during which individuals critically examine their beliefs, assumptions, and values surrounding a particular situation (Whitelaw et al., 2004).

Critical Reflection

The key for Mezirow is that people faced with disorientating dilemmas use critical reflection to alter their frames of reference, thereby altering the way they interpret and interact with others (Cranton, 1996; Mezirow, 1998; Whitelaw et al., 2004). Assumptions, beliefs, and values that form our frames of reference can be predicated on “epistemological, logical, ethical, psychological, ideological, social, cultural, economic, political, ecological, scientific, spiritual [levels] or [can] pertain to other aspects of experience” (Mezirow, 1998, p. 186). Individuals use three basic methods to interpret experiences through critical reflection: content reflection, process reflection, and premise reflection (Cranton, 1996; Cranton & King, 2003; Mezirow, 1991).

Analysis of the content or information presented through interaction with others who are experiencing a particular phenomenon is often followed by process reflection in which analysis is centered on the strategies used for problem solving instead of content. Premise reflection involves a process of analyzing the relevance of the assumptions, values, and beliefs that underlie the problem (Cranton, 1996; Cranton & King, 2003; Mezirow, 1991). Personal transformation occurs when individuals critique the premises on which they interpret and engage a phenomenon (Mezirow, 1998). This form of reflection involves questioning the problem itself rather than merely focusing on the content or process involved in a potential learning experience (Cranton & King, 2003). Eventually, individuals become enlightened on their rudimentary or potentially narrow frames of reference through the impact of the disorientating dilemma.

Through the process of engaging in a social learning process with their peers in a simulated clinical setting, nursing students may encounter challenges to their beliefs, values, and assumptions that disorientate their habits of the mind. Discourse and the testing of meaning in a group in a simulated clinical setting followed by the debriefing process will hopefully help students open up their assumptions to critique. Similar to the principles of constructivist pedagogy (Cohen, 1999; Gillani, 2003; Yilmaz, 2008), learners seek to restore homeostasis in their thinking but in doing so transform their frames of reference and how they create meaning in relation to the world and those around them.

Appropriately developed HPS-based simulated clinical scenarios have the potential to present nursing students with Mezirow’s (1995) disorientating dilemmas, which can potentially empower them to transform their learning and their frame of reference for engaging the world and their patients. Technology itself, or more specifically technology-based learning tools such as the HPS, can expose nursing students to disorientating dilemma. As Whitelaw et al. (2004) stated:

The incorporation of instructional technology into teaching practice increases complexity in an already complex environment and introduces a realm of expertise apart from the subject matter.

This results in conditions that can trigger the transformation of frames of reference. Although technology-based learning tools such as the HPS are adaptable resources to facilitate the transformation of perspective, according to transformative learning theory the social learning process requires a focus on communication and discourse to foster perspective change.

Social Discourse

Many scholars have contended that learning is most effective if it is embedded in social discourse and a group experience (Glaser, 1991; Whitelaw et al., 2004). For Mezirow (1998), true transformative learning requires dialogue and discourse “to understand the meaning of what is being communicated” (p. 188) and to filter this communication through our frames of reference. Discourse involves presenting and assessing evidence and beliefs in an attempt to find understanding and agreement, which leads to insights into a disorientating dilemma. Social discourse with groups of learners is required to validate and incorporate learning (Mezirow, 1998). The development of enlightened frames of reference requires validation through a broader range of insight than the individual possesses. Cranton (1994) noted that transformation requires considerable discussion with others to confirm new perspectives. The community in which individuals interact is influential in providing powerful norms and cultural influence.

For nurse educators, contextual settings and complex learning environments can support social discourse and the development of autonomous knowledge and meaning. Whitelaw et al. (2004) argued that authentic contextual problem solving through social discourse exposes learners to cognitive demands similar to those required to contend with real-life situations. In fostering social discourse, educators can facilitate transformative learning by creating environments that cultivate trusting and caring relationships among students (Imel, 1998). Loughlin (1993, as cited in Imel, 1998) noted that this process helps unite teachers and students in creating a learning community that is unified in trying to make meaning of a shared learning experiences. When using the term unified, it should be remembered that learners share responsibility for the quality of the learning experience in facilitating transformative learning (Imel, 1998).

By considering transformational learning theory, nurse educators can decide whether to encourage blind socialization of new nurses into the culturally influenced “norms” and instructor-centric knowledge or promote critical reflection and the development of autonomous meaning and knowledge (Cranton & King, 2003). Do we as nurse educators want to encourage students to blindly follow the culture of nursing or empower them to develop new frames of reference and thereby transform the way that nurses interact with the world? When such an approach emanates from a constructivist pedagogy, simulation-based curricula in nursing education has the potential to empower students toward transformative learning by incorporating learner-centric principles in the simulated clinical experiences, which leads to the transformative discourse of the debriefing process.

Through a Contextual Lens

Mezirow (1991) presented a set of goals for educators to consider in promoting transformative learning through the development of autonomous learning skills and in promoting learning relationships with other peers who are also experiencing a simulated clinical. These include:

  • Aiding students in performing individual learning-needs assessments.
  • Encouraging students to define and evaluate their own learning goals.
  • Promoting learning experiences that oblige students to make choices during the interaction in a group setting, thereby fostering adoption of the perspectives of others.
  • Promoting a problem-solving approach, including collaborative action and a focus on connection between personal and public issues.
  • Promoting a mutually supportive learning environment with regular feedback (noncompetitive judgment).
  • Using teaching-learning techniques that encourage modeling through the experiential and participatory engagement of learners (Mezirow, 1991).

These goals are designed to increasingly remove the students’ dependence on the teacher for guidance in creating knowledge and meaning of their world. They also reflect constructivist and emancipatory pedagogical learning principles that form the foundation of the generative learner-centric teaching tool of HPS-based clinical scenarios.

Perspective Transformation Through Simulation

Human patient simulation-based clinical nursing education has the potential to promote transformative learning and lead to a metamorphosis of students’ preconceived meaning schemes. One of its major benefits is that it allows students to engage in social interactions and hone their psychomotor skills without threatening the life of a live patient (Leigh & Hurst, 2008; Perkins, 2007). Schoening, Sittner, and Todd (2006) noted that this fact helps most students relax and increases their confidence in performing clinical skills during a simulated clinical experience.

Kolb’s (1984) experiential learning theory may also be considered in the promotion of transformative learning through HPS (Dow, 2008; Perkins, 2007). Through the use of HPS-based scenarios, students are exposed to concrete experiences, which are followed with reflective observation (i.e., debriefing). Reflection is then processed into abstract conceptualization and new theories or hypotheses are tested through active experimentation (Dow, 2008; Kolb, 1984; Perkins, 2007) during the simulated clinical scenario and the debriefing session that follows. This involves inductive process steps similar to those involved in Mezirow’s (1978) perspective transformation. By engaging in this reflective process, students are able to test their new action plans for the clinical setting (Cranton, 1994; Imel, 1998; Mezirow, 1995). Although the actual simulated clinical scenario has the potential to generate perspective transformation, debriefing and the reflective process within regarding best practices typify an activity that can alter nursing students’ meaning schemes.


The role of debriefing in enabling the transformation of meaning schemes is important to consider when analyzing the role of HPS in nursing education. With regard to adult learning principles, debriefing is undoubtedly the most important pedagogical aspect of the simulated clinical scenario. The literature highlights the notion that a quality debriefing experience takes prevalence over the actual simulation scenario itself and that learning is jeopardized without it (Leigh & Hurst, 2008; Seropian, 2003). Debriefing encourages students to reflect on their learning experience and integrate new cognitive learning from HPS-based clinical scenarios (Seropian, Brown, Gavilanes, & Driggers, 2004).

Lasater (2007) concluded that students value meaningful collaboration with each other prior to, during, and after a simulated scenario; however, debriefing in particular seems to provide the necessary reframing indicative of transformative learning. Brookfield (1986, as cited in Lasater, 2007) noted that adult learners often value peer learning groups that provide peer support for students during the process of challenging their meaning schemes. Seropian et al. (2004) corroborated this notion and stressed the usefulness of peer observations in the critical reflection process during the debriefing of a simulation experience. Values, beliefs, and assumptions can be challenged and tested more readily by groups of individuals who are “engaged in a similar quest” (Brookfield, 1986, p. 153).

The critical reflection process intrinsic to Mezirow’s (1978) perspective transformation plays a key role in simulation debriefing (Lasater, 2007). Debriefing sessions that encourage the analysis of problems occurring during the clinical scenario serve to engage learners in reassessing the how and why of problem solving indicative of Mezirow’s process of perspective transformation (Lasater, 2007). This process supports learners in developing a reflective practice in which they emphasize reflection both during and after an action is undertaken, which leads to the ultimate goal of reconceptualization (Bradley & Postlethwaite, 2003).

Bradley and Postlethwaite (2003) posited that it is vital for educators to use educational theory in guiding students toward self-reflective practice. Critical reflection imbued with theory and turned inward on educators aids in our understanding of not only how students might act differently after perspective transformation through the debriefing phase of simulation, but also in how students might think differently during the next simulated clinical scenario (Bradley & Postlethwaite, 2003). Transformative learning theory with a foundation in critical reflection has the potential to guide nurse educators in the creation of powerful learning experiences that can transform student assumptions, values, and beliefs about the world and nursing practice.

Simulation and Debriefing: Maximizing Transformative Learning

Imel (1998) explained that perspective transformation is promoted by creating a trusting, supportive learning environment to facilitate social discourse. A supportive and caring session is vital to the debriefing phase of a simulated clinical scenario (Leigh & Hurst, 2008; Seropian, 2003). Depending on the scenario, stress levels can be high following an emotional or complex experience, and Seropian (2003) advised educators to draw on a combination of self-evaluation and peer evaluation in a nonjudgmental manner, which helps defuse stress and promotes collaborative learning.

It is also important to allow sufficient time for trust to develop with regard to the practice of debriefing because both faculty and students may not trust the process at first (Leigh & Hurst, 2008; Seropian, 2003). If the goal is to foster transformation of student values, beliefs, and assumptions after a particularly stressful scenario, it is important that the facilitator not rush the process or dominate the social discourse. To do so would hinder the students in moving beyond the level of Mezirow’s content reflection (Cranton, 1996; Cranton & King, 2003; Mezirow, 1991) and they might stagnate in lower levels of abstraction, thereby preventing true perspective transformation. Seropian (2003) agreed when arguing that students learn best when they are able to create meaning from self-analysis and discussion with others.

For Leigh and Hurst (2008), another key consideration is the provision of feedback in which the facilitator addresses mistakes in a nonjudgmental manner to assist problem solving. It is important not to delay the debriefing postscenario; research has shown that students value timely feedback on simulation performance (Rhodes & Curran, 2005). Playback of a videotape of the student’s performance in the simulated clinical setting is particularly useful during debriefing because it further facilitates self-evaluation and peer evaluation (Rhodes & Curran, 2005), which not only leads to dialogue on what was done during the simulated scenario, but also answers the why questions behind actions (Leigh & Hurst, 2008). Feedback in this manner promotes reflective learning for both students and faculty that can lead to the higher levels of abstraction indicative of premise reflection in Mezirow’s (1978) perspective transformation theory.

At some stage, it is important to allow the students to direct the trajectory of the simulation process, which empowers and promotes a student-centric focus that authentically reflects the emancipatory and constructivist pedagogy that is desirable for today’s learners. With time and experience, students can not only learn from each other in creating collaborative social meanings and knowledge, but also eventually learn to debrief each other (Fanning & Gaba, 2007). This approach capitalizes on the potential of HPS-based clinical scenarios to empower the learner, which reflects the goal of autonomous thinking in transformative learning theory (Cranton & King, 2003; Mezirow, 1997).

The qualitative studies of Lasater (2007) and Smith-Stoner and Hand (2008) demonstrated the value of debriefing in promoting transformative learning. Lasater (2007) highlighted the notion that students value peer evaluation and the ideas presented during the reflective process that is inherent in debriefing. Students think that debriefing promotes flexibility in their thinking and allows them to recognize each other’s strengths (Lasater, 2007). Allowing students to assume different roles during the HPS-based clinical scenario is also important in that some participants value the ability to “step back and think more about what I would have done” (Lasater, 2007, p. 274) in a more supportive role (i.e., not the primary nurse role).

Smith-Stoner and Hand (2008) used a stressful medication error simulation as the disorientating dilemma to push students into transforming their perspective. The debriefing is considered essential in allowing the nursing students to make the connection between their experiences during the simulated clinical scenario and those in the actual world of professional practice (Smith-Stoner & Hand, 2008). Participant feedback reveals that reflective dialogue in the debriefing process leads to evidence of perspective transformation through the demonstration of a deep level of emotional involvement.

Nursing students report feeling emotion and passion for their role as nurses, which appears to create a sense of connectedness as a group of learners. Through the stress of the scenario and the subsequent debriefing process, the participants stated that they felt a transformation of their roles as both a student and a beginning practitioner (Smith-Stoner & Hand, 2008). These studies add credence to the authors’ assertion that high-fidelity HPS-based clinical scenarios in conjunction with the reflective practice of debriefing enable transformative learning for nursing students.

Smith-Stoner and Hand (2008) gave an excellent example of the ability to develop simulated clinical experiences that promote a disorientating dilemma. Human patient simulation scenarios that foster a stressful, emotionally charged learning atmosphere for nursing students can be created. Ethical or moral dilemmas can be incorporated that create Mezirow’s (1994, 1997) notion of a crisis in confronting narrow or immature frames of reference. Because the instructors ultimately control the physiological responses of the high-fidelity HPS manikin, they have the ability to allow the “patient” to decompensate in response to the students’ interventions. This further challenges the students and provides fodder for critical analysis in the subsequent debriefing section.

Concern for educators may be raised when they are under pressure of creating a crisis or a major transitional experience that is capable of altering perspectives during a simulated scenario. A nursing curriculum can be used to provide students with a series of HPS-based scenario exposures with the goal of creating incremental, compounding challenges to their meaning schemes. Mezirow (1995) and Imel (1998) argued that it is possible for transformation to occur through the gradual accumulation of related experiences. Educators should not feel pressured to always create high-stress or overly emotionally charged scenarios, especially during students’ initial exposure to HPS-based clinical scenarios.

For perspective transformation to occur, a key component of social discourse and critical reflection is the development of trust (Imel, 1998). Allowing sufficient time and repetitive opportunities to debrief promotes trust in the process (Leigh & Hurst, 2008; Seropian, 2003), which ultimately helps create collaborative learning communities. Because technology itself is potentially stressful and disorientating to the meaning schemes for adult learners (Whitelaw et al., 2004), it may be worthwhile to focus on simply experiencing simulation along with debriefing to build confidence and familiarity prior to engaging students with possible traumatic, stressful, and emotion-inducing complex clinical scenarios.

Technology-based learning tools may be unsettling to the rudimentary meaning schemes of new nursing students. This creates the need to promote incremental perspective transformation prior to the exposure of extreme disorientating dilemmas within an HPS-based scenario. When students are more experienced and comfortable with the simulated learning environment, they will likely be better able to handle the major transitional experiences brought on by high-stress or emotional scenarios.


In nursing education, HPS-based clinical scenarios are valuable tools designed to provide students with an immersive level of clinical experience prior to practice in the increasingly complex reality of the health care environment (Bearnson & Wiker, 2005; Yeager et al., 2004). Unfortunately, little research has been undertaken to analyze the pedagogy underlying this powerful technology-based educational tool (Day-Black & Watties-Daniels, 2006; Mallow & Gilji, 1999). If a goal of nursing education is the socialization of graduates into the professional role of nurse (Lindeman, 2000), then methods are needed that encourage students to critically reflect on their own assumptions, beliefs, and values that affect how they interpret and interact with the world. Transformative learning theory has the potential to assist students in altering their particular frames of reference (Cranton & King, 2003; Imel, 1998; Mezirow, 1994).

Human patient simulation-based clinical scenarios offer students the requisite opportunities to be exposed to disorientating transitional experiences during the scenario and the critical reflection and social discourse that accompany the debriefing process. For senior nursing students with prior simulation experience, scenarios can be developed that provide emotionally charged experiences that lead to more sudden alterations of the learner’s frame of reference; in the case of novice nursing students, the challenge of technology that the HPS poses and simple role experience without the complexity of an emotion-charged event can lead to incremental, gradual change in perspective.

Regardless of the seniority of the student, it is important to promote critical reflection and social discourse to enable students to develop peer-evaluation skills and collaborative, student-driven learning communities. With an understanding of transformative learning theory, nurse educators can maximize the flexibility and alterability of the HPS-based clinical scenario process to empower students to become autonomous thinkers who are able to contend with the complexities of today’s health care environment.


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Mr. Parker is a PhD candidate, Faculty of Nursing, University of Alberta, and Faculty, Faculty of Health and Community Studies, Grant MacEwan University, and Dr. Myrick is Professor and Associate Dean, Teaching Learning, Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada.

The authors have no financial or proprietary interest in the materials presented herein.

Address correspondence to Brian Parker, BScN, RN, RPN, Faculty of Nursing, 3rd Floor Clinical Sciences Building, University of Alberta, Edmonton, Alberta, Canada T6G 2G3; e-mail:


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