Journal of Nursing Education

Major Article 

The Pedagogical Ebb and Flow of Human Patient Simulation: Empowering Through a Process of Fading Support

Brian Corey Parker, PhD, RN; Florence Myrick, PhD, RN


The use of the high-fidelity human patient simulator (HPS)-based clinical scenario in undergraduate nursing education is a powerful learning tool, well suited to modern nursing students’ preference for immersive construction of knowledge through the provision of contextually rich reality-based practice and social discourse. The purpose of this study was to explore the social–psychological processes that occur within HPS-based clinical scenarios. Grounded theory method was used to study students and faculty sampled from a Western Canadian baccalaureate nursing program. The process of leveled coding generated a substantive theory that has the potential to enable educators to empower students through the use of fading support, a twofold process composed of adaptive scaffolding and dynamic assessment that challenges students to realistically self-regulate and transform their frame of reference for nursing practice, while limiting the threats that traditional HPS-based curriculum can impose.


The use of the high-fidelity human patient simulator (HPS)-based clinical scenario in undergraduate nursing education is a powerful learning tool, well suited to modern nursing students’ preference for immersive construction of knowledge through the provision of contextually rich reality-based practice and social discourse. The purpose of this study was to explore the social–psychological processes that occur within HPS-based clinical scenarios. Grounded theory method was used to study students and faculty sampled from a Western Canadian baccalaureate nursing program. The process of leveled coding generated a substantive theory that has the potential to enable educators to empower students through the use of fading support, a twofold process composed of adaptive scaffolding and dynamic assessment that challenges students to realistically self-regulate and transform their frame of reference for nursing practice, while limiting the threats that traditional HPS-based curriculum can impose.

Dr. Parker is Faculty, Faculty of Health and Community Studies, Grant MacEwan University, Ponoka; and Dr. Myrick is Professor and Associate Dean, Teaching & Learning, Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Brian Corey Parker, PhD, RN, Faculty, Faculty of Health and Community Studies, Psychiatric Nursing Program, Grant MacEwan University, Dave Russell Education Complex, Centennial Centre for Mental Health and Brain Injury, Box 1000, Ponoka, Alberta T4J 1R8, Canada; e-mail:

Received: October 11, 2011
Accepted: April 04, 2012
Posted Online: May 09, 2012

High-fidelity human patient simulation (HPS) is a technology-based learning tool that is undergoing increased usage on an international level in undergraduate nursing programs (Harder, 2010; Murray, Grant, Howarth, Leigh, 2008; Nehring, 2008). Many scholars view this as an approach to learning that helps students to augment the acquisition of clinical skills by providing a contextual reality-based learning environment (Cant & Cooper, 2009; Cooper & Taqueti, 2007; Day-Black & Watties-Daniels, 2006). Immersive reality-based learning experiences, such as simulation, also appeal to learners who prefer nonlinear thinking and desire active participation in knowledge construction (Harder, 2010; Pardue, Tagliareni, Valiga, Davison-Price, & Orehowsky, 2005). Therefore, HPS-based clinical scenarios with a foundation in exploratory learning and constructivist pedagogy are well suited to meeting these learning needs (Parker & Myrick, 2009). Despite the apparent benefits of incorporating HPS-based learning experiences into undergraduate nursing programs, limited research is available to help educators incorporate sound pedagogical practices that are best designed to meet the needs of modern adult learners (Cant & Cooper, 2009; Cooper & Taqueti, 2007; Day-Black & Watties-Daniels, 2006; Kaakinen & Arwood, 2009; Rourke, Schmidt, & Garga, 2010). Unfortunately, the current state of knowledge affirms that nursing has embraced simulation without waiting for sufficient inquiry into the processes that occur in a HPS-based clinical scenario to better inform the application of pedagogical practices.

Significance and Purpose of the Study

It is the contention of the researchers that undergraduate nursing students’ participation in an HPS-based clinical scenario is a social endeavor that conforms to millennial learners’ preference for immersive, reality-based, and collaborative construction of knowledge. High-fidelity simulation appears to provide students with an active learning session that uses social discourse processes that ultimately lead to the creation of socially derived meanings (Lasater, 2007; Leigh & Hurst, 2008; Parker & Myrick, 2010; Perkins, 2007). This social construction of knowledge and its inherent linguistic symbols are then incorporated into individual frames of reference surrounding nursing practice. Unfortunately, research undertaken to analyze the social and psychological process in which the students engage when they participate in an HPS-based clinical scenario is lacking (Day-Black & Watties-Daniels, 2006). Therefore, the purpose of this study was to explore these social–psychological processes that occur within HPS-based clinical scenarios to inform nurse educators on their choice of pedagogy in developing simulation-based learning experiences that are relevant to modern nursing students.

Current State of Knowledge

The current state of knowledge on the use of HPS-based clinical scenarios in undergraduate nursing education can be channeled into two predominant areas of focus, the first of which is the perceptions of key stakeholders (e.g., students and faculty) regarding the efficacy of this technology-based learning tool (Bremner, Aduddell, Bennett, & VanGeest, 2006; Buckley & Gordon, 2010; Childs & Sepples, 2006; Feingold, Calaluce, & Kallen, 2004; Foster, Sheriff, & Cheney, 2008; Lasater, 2007; Leonard, Shuhaibar, & Chen, 2010; Mould, White, & Gallagher, 2011; Smith-Stoner & Hand, 2008). The second area of focus is empirical evidence of improved knowledge retention, improved performance of clinical skills, or both, as a result of exposure to HPS-based clinical scenarios (Alinier, Hunt, & Gordon, 2004; Alinier, Hunt, Gordon, & Harwood, 2006; Brannan, White, & Bezanson, 2008; Cant & Cooper, 2009; Elfrink, Kirkpatrick, Nininger, & Schubert, 2010; Kruglikova, Grantcharov, Drewes, & Funch-Jensen, 2010; Levett-Jones, Lapkin, Hoffman, Arthur, & Roche, 2011). Harder’s (2010) systematic literature review provides further evidence of the positive impact of HPS on skill acquisition in nursing and related health care disciplines. Harder noted that the majority of the 23 studies she reviewed showed increased skill acquisition with the use of performance testing (e.g., objective structured clinical examination, pretesting and posttesting, or a combination of the two). Despite this evidence, Harder argued that the lack of formal evaluation tools designed specifically for simulation evaluation casts doubt on whether any of the studies reviewed were able to adequately appraise the effects of simulation on the acquisition of clinical skills.

In a summative sense, if the current state of knowledge is too focused on being merely descriptive (Rourke et al., 2010) or residing in the scientific paradigm (Bradley & Postlethwaite, 2003), is unable to demonstrate external validity (Harder, 2010; Leigh, 2008; Ravert, 2002), or lacks a theoretical foundation (Kaakinen & Arwood, 2009; Rourke et al., 2010), then there is a need to engage in further modes of inquiry to contribute to a knowledge base from which nurse educators can draw to inform fundamentally sound pedagogical decisions regarding the development of simulation-based curriculum.


Research Questions

The primary question that guided this study was: What is the social–psychological process involved in using HPS as a teaching–learning modality to educate undergraduate nursing students? Intrinsic to this question were the following:

  • How does educational theory or pedagogy guide the faculty in using HPS as a teaching modality?
  • According to the participants, how is HPS best structured to respond to the learning needs of the neomodern adult learner?
  • What is the process used to integrate educational theory or pedagogy into the development and implementation of clinical scenarios for HPS-based teaching?

Research Design

Given the lack of externally valid research in the area of HPS use in nursing education, a grounded theory method, specifically Glaserian grounded theory, was used to explore the social–psychological process involved in using HPS as a teaching–learning modality to educate undergraduate nursing students. For the purpose of exploring HPS-based clinical scenarios, the grounded theory method is valuable because it serves to identify and conceptualize formerly unidentified variables (Wuest, 2007; Wuest & Stern, 1990). Glaser’s (1978) focus on conceptualizations is well suited to this particular chosen area of inquiry because of the lack of research, to date, on the social–psychological process involved in the simulation teaching–learning experience. Owing to the insufficient research to guide the application of pedagogy in HPS-based nursing education (Cant & Cooper, 2009; Kaakinen & Arwood, 2009; Rourke et al., 2010), the higher level of abstraction and conceptualization that are characteristic of Glaserian grounded theory better lent itself to the creation of a foundational mid-range theory. Thus, the intent of this theory is to assist nurse educators in making evidence-informed decisions on the use of pedagogy in simulation-based nursing education.

Data Collection

Prior to the initiation of the study, permission was acquired from the vice-dean in a degree-granting academic institution in a large urban area in Western Canada. The same institution’s ethics review committee also granted ethical approval. The data collection involved semistructured interviews supplemented by observation sessions in which cohorts of undergraduate nursing students engaged in HPS-based clinical scenarios. Data collection also included field notes, analytical and operational memos, and journaling in which we recorded personal reflections, which in turn provided contextual depth during the analysis of the data. All participants signed a consent form to indicate their awareness of their rights as study participants.

Sixteen interview participants were recruited, and a total of 45 interviews were conducted, all 45 of which were transcribed verbatim. Of the 16 participants, 5 were faculty members with prior experience as HPS-based clinical scenario facilitators, and 11 were Bachelor of Science in Nursing (BScN) students with prior experience in HPS-based clinical scenarios as part of their formal education program. The majority of the interviews ranged from 30 to 60 minutes. The use of leveled coding inherent in the grounded theory process served as a guide in helping to determine the number of interviews required to reach data saturation (see the Data Analysis section for a more detailed description of the leveled coding process). The observation sessions involved another 28 fourth-year BScN students and two faculty members who actively participated in simulated clinical scenarios. Initially, to conduct the interviews, interview guides were used that contained open-ended questions. Examples of open-ended questions included “How would you describe the simulated clinical scenario?” and “How would you say that you learn from the simulated clinical scenario?” These interview guides were designed only to ensure systematic data collection at the start and were subsequently revised as data and the thematic categories emerged. Finally, secondary data were also acquired from the observation sessions by using an observation guide to focus on relevant phenomena when the live HPS-based clinical scenarios were viewed. Examples of questions used to guide the observation sessions included “What is the basic structure and organization unfolding during the HPS-based clinical scenario?” and “How do nursing students interact with their peers during the scenario and the subsequent debriefing session?”

Data Analysis

Coding is considered the primary analytical procedure in a grounded theory study (Walker & Myrick, 2006); it is “an iterative, inductive, yet reductive process that organizes data, from which the researcher can then construct themes, essences, descriptions, and theories” (p. 549). Coding is achieved by de-fragmenting the data and comparing and labeling newly created categories that are useful in the data analysis (Glaser, 1978; Walker & Myrick, 2006). The basic process of leveled coding in grounded theory includes open coding, selective coding, and theoretical coding. The aim of creating codes from the data and constantly comparing them with the data is to generate categories that lead to the emergence of a core variable (Glaser, 1978; Schreiber, 2001) that will provide insight into the process involved in using the HPS-based clinical scenario experience as a teaching modality for undergraduate nursing students.

During this study we extracted data fragments, stories, or individual words from the nursing students’ and faculty members’ descriptions of the simulation experience. Through the process of selective coding, we eventually conceptualized these open codes into 38 selective codes, which directly contributed to the core variable that emerged from this study. Examples of selective codes that emerged from this process included “hierarchal observation,” “crawling before you walk,” and “talking to the wall.” During Glaser’s (1978) second main level of coding, theoretical coding, we analyzed the relationships among the substantive codes or categories to form conceptualizations of a possible theory or central theme (Schreiber, 2001; Walker & Myrick, 2006). Examples of some of the key substantive categories from this study included “presence as support,” “leveling noise,” and “performing in the fishbowl.” At this point in the analysis process, flexibility was needed to adjust the central theme as dictated by the data. This flexibility contributed to a core variable or emerging theory that echoed the relationships between and among the substantive codes (McCann & Clark, 2003a).


Chiovitti and Piran (2003) stated that trustworthiness in qualitative research is related to credibility, and Beck (1993) argued that the credibility of a qualitative study is judged by “how vivid and faithful the description of the phenomenon is” (p. 264) to the participants’ experience. Therefore, we used two sets of criteria to enhance the rigor and trustworthiness of this study (Chiovitti & Piran, 2003; Glaser, 1978). The first set is Glaser’s four criteria for judging and improving the generalizability of grounded theory: fit, work, relevance, and modifiability (Glaser, 1978; McCann & Clark, 2003b); the second is Chiovitti and Piran’s (2003) criteria for qualitative research rigor: credibility, auditability, and fittingness. Throughout this study, we took specific actions to ensure that we followed these criteria to maintain the rigor of the study.

Findings and Discussion: Empowering Through Fading Support

In this study, a multidimensional social–psychological process was uncovered, which occurred during the use of a high-fidelity HPS-based clinical scenario as a teaching–learning modality to educate undergraduate baccalaureate nursing students. This process was identified as empowering through fading support, which is illustrated in the theoretical diagram presented in the Figure. As demonstrated in the Figure, fading support indicates a process that involves dynamic assessment or adaptive scaffolding as a foundation for the social construction of knowledge inherent in the simulated clinical environment. Application of adaptive scaffolding is further enhanced by the use of teaching strategies (Figure) that empower nursing students to move beyond the initial stage of other-control toward the stage of self-control or self-regulation of the HPS-based clinical scenario learning environment that promotes knowledge relevant to the learner and their maturing frame of reference.

The process of empowering through fading support in high-fidelity human patient simulation (HPS).

Figure. The process of empowering through fading support in high-fidelity human patient simulation (HPS).

Lajoie (2005) used the term adaptive scaffolding to refer to an evolution of the practice of scaffolding that is most closely connected with Vygotsky’s (1978) social learning theory, which asserts that learning occurs within a zone of proximal development (ZPD). Vygotsky defined the ZPD as “the distance between the actual developmental level as determined by independent problem solving and the level of potential development as determined through problem solving…in collaboration with more capable peers” (p. 86). Scaffolding enters into play when someone more competent at completing the task (e.g., a teacher) supports learners within their ZPD. The teacher begins by supporting the aspects of a task or activity that are outside the learners’ current capacities, which in turn frees them to focus on aspects of the task or activity that are within their current scope of knowledge and understanding (Stone, 1998). This support, or scaffold, is only temporary, and the teacher gradually removes it as the learners begin to take control of the learning experience (Stone, 1998). This support is enhanced by dynamic assessment, which refers to the need for the teacher to actively assess the learners’ ZPD as the learning session unfolds and to decide when to scaffold (support) or when to fade (withdraw support; Lajoie, 2005; Lajoie & Lesgold, 1992). Key to this theory is the concept that scaffolding must be seen as fluid in nature, fading in and out, which thereby avoids the overuse of rigid objectives (Hadwin, Wozney, & Pontin, 2005; Lajoie, 2005; Stone, 1998). Therefore, the term fading support is best understood as a process of gradual withdrawal of support or assistance as the students move from the beginning phase (where others regulate their learning) to the final phase of self-regulation (Hadwin et al., 2005). In accordance with the process of fading support highlighted in this study, we argue for the need to bring learner-centric adaptive scaffolding into a dialectical blend of instruction and assessment when nursing students are engaged in an HPS-based clinical scenario.

The thematic analysis of the findings from this study is reflected not only in Vygotsky’s (1978) social learning theory, but also in Mezirow’s (1994, 1995) transformative learning theory. At the heart of transformative learning theory is the concept that learners develop habits of the mind (understandings and meanings) through experiences (Cranton & King, 2003; Mezirow, 1994). These habits of the mind form a rudimentary frame of reference surrounding a phenomenon that leads individuals to think that this phenomenon will invariably occur in the same way again (Cranton & King, 2003; Mezirow, 1994). According to Mezirow (1994), a frame of reference incorporates a “constellation of concepts, beliefs, judgments, and feelings which shape a particular interpretation” (p. 223). Mezirow (1995) explained that learning occurs when these rudimentary frames of reference are upset and reformulated through learning experiences or “disorientating dilemmas” (p. 50) that challenge our values, assumptions, and beliefs. Similar to the constructivist learning theory, learning occurs when students critically reflect on their meaning schemes that are upset by this disorientating dilemma, which leads to the transformation of their perspectives on the phenomenon (Cranton & King, 2003).

Performing in the Fishbowl

The following analysis of the substantive categories that emerged from the study demonstrates the core variable of empowering through fading support. This analysis begins with the theme of performing in the fishbowl. Performing in a fishbowl refers to a complex social process within the simulated clinical environment that requires students to submit to peer observation while they “perform” during the HPS-based clinical scenario, with the goal of facilitating feedback and fostering peer filtering of knowledge in the subsequent debriefing session. The act of being observed by a cohort of fellow students as they participate in a scenario often appears to evoke feelings of fear, stage fright, and an implicit sense of judgment. As one student reported:

When I think of the word simulation and that experience, a big word that comes to my mind is fear, anxiety, performance anxiety.… The tension in the room is—you can feel it.… I have tried to break the tension by reminding us as a group that, Hey, we’re not being graded, blah, blah, blah; but it has had little effect on the wall of fear.

Another student described his or her discomfort with peer observation:

In first year especially, when there was discomfort with having our peers watch us, you really weren’t thinking in there. You pretty much freeze up.… You’re just concerned with getting out of that room.

These feelings of fear, anxiety, and even intimidation related to performance anxiety are well corroborated throughout the literature (Cant & Cooper, 2009; Decarlo, Collingridge, Grant, & Ventre, 2008; Lasater, 2007; Lundberg, 2008). However, acknowledging the vital role of social discourse in transformative learning (Parker & Myrick, 2010) and social learning theories, Tinsley and Lebak (2009) advocated for the use of collaboration when undertaking the social filtering of peer knowledge. Feedback and evaluation in a group setting help to develop learners’ capacity for critical reflection (Tinsley & Lebak, 2009). The data provided further evidence of the benefits of peer filtering of knowledge in the observation and debriefing processes, as one student noted:

But what was really powerful learning…was from debriefing. So maybe being in a situation and panicking and being shell-shocked and not knowing what you’re doing, and then being given the information does have value.

Statements such as this one give credence to the role of disorientating dilemmas in the simulated clinical environment to facilitate the transformation of meaning perspectives (Mezirow, 1995; Parker & Myrick, 2010).

Finally, developing trust and building relationships with peers and teachers in the simulated environment was a significant theme throughout the study. A student participant stressed the need for relationship and accountability among observers offering critique:

In sim lab…the people sitting in the room weren’t your colleagues, right? It wasn’t the feedback that you would receive from a colleague on the floor.… It was, again, people watching you and scrutinizing. So to me there was not the accountability or the relationship that needs to be there to give that kind of feedback in a work setting.

The data clearly indicate the need for trust and accountability of peers when students engage in the social discourse of peer observation and critique that are inherent in the high-fidelity simulated clinical scenario experience.

Suspending Disbelief

Another theme closely related to the challenge of performing in a fishbowl is the significant challenge to students of suspending their disbelief when they engage with a high-fidelity simulated mannequin. For the students, this finding was a consistent theme that was typified in statements such as, “It’s creepy looking; it really is. And it’s got this silly wig and the blinking of the eyes. Those eyes!” The students also noted the challenge of engaging the mannequin on a human level: “You’re not actually getting the whole artificial patient.” This experience raised the issue of students’ inability to look past the mannequin’s mechanical limitations as a defense mechanism to avoid engaging with it on a subhuman level because of their feelings of insecurity about their knowledge with regard to both the mannequin and the application of their skills within a clinical scenario. One faculty member spoke about the choice of some students to disengage the suspension of their disbelief: “Some students do it very well, and those that can’t dispel that disbelief will talk to the mirror or talk to the air but not directly to the patient because they are having difficulty.” The concept of this kind of disengagement in the learning process can often be related to learners’ underdeveloped capacity to cognitively process disorientating dilemmas. This phenomenon was especially prevalent when the technician used the mannequin’s (patient’s) voice to cue or prompt the students; it is believed to be a factor in feelings of disengagement and the interrelated inability to suspend disbelief.

The students repeatedly found the simple act of cueing or prompting through the voice of the mannequin (patient) that often occurs during a clinical scenario disconcerting and connected to a strong desire to maintain the authenticity of the roles within the simulation laboratory. One student stated:

Of course the location where the voice is coming from, not being the mannequin and all, that is a bit off-putting; but also when the voice changes from being the patient to trying to push you in a different direction than where you’re going kind of makes you very confused, you think you’re missing something major.

Maintaining authentic roles within the simulated learning environment is paramount not only to the process of suspending disbelief but also to engaging adult learners. The perceived authenticity of the learning experience is key to maximizing the learning benefits of simulation (Hotchkiss, Biddle, & Fallacaro, 2002; Reid-Searl, Eaton, Vieth, & Happell, 2011).

Scaffolding Signal and Noise

In structuring an HPS-based clinical scenario, educators often imbue the experience with the realities of the clinical environment to provide students with an accurately contextualized clinical experience in which to apply their burgeoning skills, knowledge, and meaning schemes before they enter the real world. To this end, educators can introduce complexity and acuity into an experience, which we call “signal and noise.” A faculty member explained:

Signal is, in a first-year student you want them to be able to check vital signs; you want them to be comfortable learning that. And noise is the concept of throwing tons of things at them; like the patient is fidgeting, won’t keep their arm still. If you throw tons of noise at a first-year student, you’re inhibiting the knowledge that can be gained.

Signals such as interpersonal complexity or conflict and increasing physiological acuity can quickly become noise that overwhelms junior learners and hampers their ability to cognitively process the noise if they lack the experience and confidence that indicate mature frames of reference with regard to a particular phenomenon. For example, a student discussed the introduction of role-players, such as family members, into a simulated clinical scenario:

I found that I could explain things easier to the family because I was in fourth year and had gone through all the education prior.… I think had I been in year two and had a family member complicating the scenario, I think I would have been done for.

With reference to the mannequin’s (patient’s) sudden change in acuity, another student stated:

We were supposed to go in and do a head to toe, do vitals, and work together in a team; however, when we got into that room, and hearing that this person is cycling downward, I panicked.

These comments reflect the potential for HPS-based learning experiences to move beyond signal to noise that will overwhelm learners cognitively.

Scaffolding the Expert’s Presence

Students who participate in HPS-based simulated clinical scenarios yearn for the experts’ assistance and contributions to their burgeoning knowledge with regard to clinical skills and interventions. One student noted:

I hungered for more times with the tutor where you had a partnership…if you have your tutor there and they can demonstrate… rather than leave you to guess all the time; to model, because they know we are the blind leading the blind in that room, right?

This statement is typical of the thematic trend throughout the data that the participants, especially those who were new to high-fidelity simulated scenarios, strongly preferred student collaboration with experienced tutors who are able to bring the contextual expertise they have drawn from the realities of the clinical environment. Collaboration or guidance from perceived clinical experts decreases the anxiety and stress of performing in the fishbowl of peer-observed simulated scenarios, as evident in this student’s comment:

There are times in that room as a student when we flounder; we don’t have a clue what to do.… In those moments of sheer panic, if you can look at a friendly face like a tutor that you had good rapport with, then I think it would make it less sterile.

For the researchers, statements such as these move the concept beyond the realm of the learners’ mere desire for guidance to a desire to perhaps borrow and eventually assimilate an expert’s frame of reference. This inclination is perhaps a result of their need to shelter themselves during the scenario performance by considering the expert’s knowledge and skills a form of intellectual support for their own rudimentary frames of reference and lack of confidence.

Although the desire for expert collaboration with students in the scenario itself and expert guidance in the subsequent debriefing session was strong, clearly there was a call for adaptive scaffolding of the instructors’ contributions in all facets of the HPS-based clinical scenario facilitation. Thematic trends demonstrated that as students gained clinical and theoretical experience during the course of their educational programs, the perceived desire for expert collaboration decreased or fluctuated. One student highlighted this need:

As you become a more senior student you become more confident in your own abilities, in your assessment skills.… You should actually feel like you don’t want her there to give you a chance to think things through.

Self-control ultimately requires dynamic assessment, which thereby creates the ebb and flow of the expert’s support and presence. HPS-based clinical scenarios are a prime environment in which to facilitate the perspective transformation from other-control (teacher-centric) to self-control (learner-centric) through the development of social communities of practice.

Scaffolding Expectations of the Learner

Lantoff (2009) cautioned that “it makes little sense to talk of acquisition unless one intends to use what one has acquired, and it makes even less sense to talk of using something that one has not yet acquired” (p. 356). Key to that process of empowering through fading support in HPS-based clinical scenarios is the need for nurse educators to scaffold their expectations of learners. Overshadowing this study is the call for educators to facilitate simulation learning experiences by targeting nursing students’ ZPD, thereby increasing the learners’ capacity for the simulated scenario based on an assessment of their developmental levels and frames of reference. With regard to simulation, one student noted, “I think the students find it stressful enough already if you try to make them move beyond what they’ve been taught. Yeah, it’s overwhelming.” Another faculty member’s comment on the use of adaptive scaffolding validated the role of personal experience and the current frame of reference in enhancing nursing students’ learning through simulation:

We have to start where the students are at. We think it confirms for them the purpose of the experience, and it validates that, yes, they can contribute, or they have something to bring to the situation.

Orientation and prior preparation are key activities highlighted in the data that augment the students’ capacity to engage effectively in the simulated clinical scenario and the inherent peer observation process. The students typically referred to being “freaked out” or “put on the spot”; one student commented further that she:

didn’t feel prepared in first year. Being thrown in there was scary. And . . . you were just given the scenario, you didn’t have time to plan how you would deal with the situation. So that was mostly why I felt like I just wanted to get out.

Conversely, the students considered receiving information prior to an upcoming scenario a “confidence booster” because it gave them an opportunity to research and increase their knowledge of pathophysiology and nursing interventions. Students also considered blending their previous knowledge from laboratory experiences, theoretical knowledge, and clinical practice key to maximizing their learning in the simulated clinical environment.

Scaffolding Within the Facilitator’s ZPD

Given the need for adaptive scaffolding that emerged from the data, simulation curriculum developers would be negligent if they did not consider facilitators’ own frames of reference with regard to mediating HPS-based clinical scenarios. The process of learning, especially in a practice environment, requires a relationship or interchange of knowledge and meaning schemes between both the expert and the learner (Lave & Wenger, 2002). This process requires that educators have knowledge of learning theory and process that is best suited to simulation. They must be aware of their own ability to assess learners’ needs and their own capacity for ambiguity and flexibility in structuring high-fidelity simulated learning experiences. One faculty participant stated:

The tutors need to have some leveling up in terms of how they are able to do the observation or the questioning.… Maybe we should look at leveling the tutors with their own skill.

Self-awareness and knowledge of learning theory are key factors in the development of pedagogically sound HPS-based clinical scenario curricula.

In reference to pedagogy in simulation, Kaakinen and Arwood (2009) called for educators to shift from traditional simulation delivery models based on a teaching paradigm to those based on a learning paradigm. Most high-fidelity simulated clinical scenarios are facilitated based on structured objectives and goals. The move beyond reliance on behaviorist pedagogy is reflected in a statement from a student on the structuring of predetermined objectives for the scenario:

The expectation of the student is that “I’m going to walk in there and do my assessment, and I need to find something, and then I need to treat it, and that is how I’m going to get out.… What’s the quickest way to get out of here?” That is kind of like a puzzle.

These pedagogical principles are also reflected in a faculty participant’s statement:

As facilitators, we assist students to understand the potential for their learning.… We need to stop focusing on particular tasks and getting things right, as opposed to learning.

Scholars contend that simulation has the potential to engage the millennial generation of learners through nonlinear exploratory learning constructs (Harder, 2010; Pardue et al., 2005Parker & Myrick, 2009). Therefore, adaptive scaffolding or dynamic assessment may be the foundation for the development of sound pedagogy suited to high-fidelity undergraduate simulation.

Implications and Recommendations

Several key concepts have been identified within this study, which can inform the knowledge base of nursing faculty involved in developing and implementing HPS as a teaching–learning modality in undergraduate nursing education. These concepts are further reflected within the teaching strategies identified in the Figure. First, it was found that the act of observation and critique of an individual’s scenario performance by peers can cognitively overwhelm a novice learner. A risk of severely hampering learning in a high-fidelity simulated practice environment exists until nursing students gain more experience and confidence. Second, the challenge to students to suspend the disbelief that is ubiquitous in HPS-based learning sessions is also related to the need to build capacity through experience and the maturation of their frames of reference. Key evidence that supports this concept involves the possible use of disbelief as a defense mechanism when learners are confronted with the threat of observation and performance anxiety. Third, the intentional introduction of noise (e.g., interpersonal conflict, physiological changes in acuity, or both) can also overwhelm students who lack the experience and confidence to integrate the knowledge and skills embedded in the scenario. Fourth, there is a need to assimilate or have access to an expert’s frame of reference through collaboration. The presence of the instructor during the scenario and the subsequent debriefing session should help to decrease the threat of observation, the mannequin’s limitations, and the introduction of signal and noise. Finally, there is a need that simulation facilitators be self-aware, critically reflexive, and able to tolerate ambiguity of individualized HPS-based clinical scenarios. This reflexivity necessitates that faculty be knowledgeable about learning theories and pedagogical practices that maximize the potential of this technology-based learning tool.


Limitations regarding the findings of this study are as follows: First, the researchers’ ability to analytically conceptualize the aforementioned interrelated phenomena can always be an issue (Glaser, 1978). Second, personal bias on our part is also a factor that may unavoidably cloud the findings. However, grounded theory to some extent limits this bias because it is designed to analyze the participants’ perspectives and thus increase the likelihood that the findings will be unencumbered by the researcher’s ideological stance (Glaser, 1998; Milliken & Schreiber, 2001). Finally, the primary mode of data collection was interview based, which raises questions about the participants’ representations of their perspectives of the process. Grounded theory mechanisms, such as leveled coding, purposive sampling, and member checking, were used to promote rigor and aid in circumventing these limitations.


From this study, a viable mid-range theory on the social–psychological processes involved in using HPS-based clinical scenarios as a teaching–learning modality in undergraduate nursing education has emerged. Contextual conceptualization of the participants’ realities regarding the phenomenon of high-fidelity simulated scenarios has revealed how the process of fading support with the ebb and flow of adaptive scaffolding can provide nurse educators with a framework to implement scenarios that are best suited to the learning needs and preferences of modern nursing students. Vital to this framework is the role of dynamic assessment in the use of this technology-based learning tool. Without formative assessment and the inherent development of reciprocal learning partnerships among students and educators, we risk propagating the inherent threats that traditional simulated clinical sessions can impose on learners’ esteem, confidence, and frames of reference.

It is evident that faculty members who are responsible for the facilitation of high-fidelity HPS-based simulated clinical scenarios must look beyond structured scaffolding and over-reliance on predetermined objectives to best meet the learning needs of today’s undergraduate nursing students. This process requires that educators be willing to both embrace ambiguity in the learning sessions and challenge their meaning schemes with regard to the effects of limited resources on pedagogical practices. To this end, critical reflectivity must be a cornerstone of the structuring of the framework for the implementation of HPS-based clinical scenarios that enhance knowledge and skills relevant to the realities of modern clinical practice. In conjunction with this reflexivity is the need for further analysis of the social processes that occur within a high-fidelity simulated learning environment. Morse (2001) indicated that the inductively derived theories that emerge from grounded theory can often become springboards for future studies.

We hope that the substantive theory that emerged from this study will help form the groundwork for other studies that draw from both inductive and deductive methodologies and thereby build a body of knowledge well suited to inform our pedagogical choices as nurse educators in HPS-based clinical scenarios.


  • Alinier, G., Hunt, B. & Gordon, R. (2004). Determining the effect of realistic simulation in nurse education: Study design and initial results. Nurse Education in Practice, 4, 200–207. doi:10.1016/S1471-5953(03)00066-0 [CrossRef]
  • Alinier, G., Hunt, B., Gordon, R. & Harwood, C. (2006). Effectiveness of intermediate-fidelity simulation training technology in undergraduate nursing education. Journal of Advanced Nursing, 54, 359–369. doi:10.1111/j.1365-2648.2006.03810.x [CrossRef]
  • Beck, C.T. (1993). Qualitative research: The evaluation of its credibility, fittingness, and auditability. Western Journal of Nursing Research, 15, 263–266. doi:10.1177/019394599301500212 [CrossRef]
  • Bradley, P. & Postlethwaite, K. (2003). Simulation in clinical learning. Medical Education, 37(1), 1–5. doi:10.1046/j.1365-2923.37.s1.1.x [CrossRef]
  • Brannan, J.D., White, A. & Bezanson, J.L. (2008). Simulator effects on cognitive skills and confidence levels. Journal of Nursing Education, 47, 495–500. doi:10.3928/01484834-20081101-01 [CrossRef]
  • Bremner, M.N., Aduddell, K., Bennett, D.N. & VanGeest, J.B. (2006). The use of human patient simulators: Best practices with novice nursing students. Nurse Educator, 31, 170–174. doi:10.1097/00006223-200607000-00011 [CrossRef]
  • Buckley, T. & Gordon, C. (2010). The effectiveness of high fidelity simulation on medical-surgical registered nurses’ ability to recognize and respond to clinical emergencies. Nurse Education Today, 31, 716–721. doi:10.1016/j.nedt.2010.04.004 [CrossRef]
  • Cant, R.P. & Cooper, S.J. (2009). Simulation-based learning in nurse education: Systematic review. Journal of Advanced Nursing, 66, 3–15. doi:10.1111/j.1365-2648.2009.05240.x [CrossRef]
  • Childs, J.C. & Sepples, S. (2006). Clinical teaching by simulation: Lessons learned from a complex patient care scenario. Nursing Education Perspectives, 27, 154–158.
  • Chiovitti, R.F. & Piran, N. (2003). Rigour and grounded theory research. Journal of Advanced Nursing, 44, 427–435. doi:10.1046/j.0309-2402.2003.02822.x [CrossRef]
  • Cooper, J.B. & Taqueti, V.R. (2007). A brief history of the development of mannequin simulators for clinical education and training. Quality and Safety in Health Care, 13, 1118.
  • Cranton, P. & King, K.P. (2003). Transformative learning as a professional development goal. New Directions for Adult and Continuing Education, 98, 31–37. doi:10.1002/ace.97 [CrossRef]
  • Day-Black, C. & Watties-Daniels, A.D. (2006). Cutting edge technology to enhance nursing classroom instruction at Coppin State University. ABNF Journal, 17, 103–106.
  • Decarlo, D., Collingridge, D.S., Grant, C. & Ventre, K.M. (2008). Factors influencing nurses’ attitudes toward simulation-based education. Simulation in Healthcare, 3, 90–96. doi:10.1097/SIH.0b013e318165819e [CrossRef]
  • Elfrink, V.L., Kirkpatrick, B., Nininger, J. & Schubert, C. (2010). Using learning outcomes to inform teaching practices in human patient simulation. Nursing Education Perspectives, 31, 97–100.
  • Feingold, C.E., Calaluce, M. & Kallen, M.A. (2004). Computerized patient model and simulated clinical experience: Evaluation with baccalaureate nursing students. Journal of Nursing Education, 43, 156–163.
  • Foster, J.G., Sheriff, S. & Cheney, S. (2008). Using nonfaculty registered nurses to facilitate high-fidelity human patient simulation activities. Nurse Educator, 33, 137–141. doi:10.1097/01.NNE.0000312186.20895.50 [CrossRef]
  • Glaser, B. (1978). Theoretical sensitivity: Advances in the methodology of grounded theory. Mill Valley, CA: Sociology Press.
  • Glaser, B. (1998). Doing grounded theory. Mill Valley, CA: Sociology Press.
  • Hadwin, A.F., Wozney, L. & Pontin, O. (2005). Scaffolding the appropriation of self-regulatory activity: A socio-cultural analysis of changes in student-teacher discourse about a graduate research portfolio. Instructional Science, 33, 413–450. doi:10.1007/s11251-005-1274-7 [CrossRef]
  • Harder, B.N. (2010). Use of simulation in teaching and learning in health sciences: A systematic review. Journal of Nursing Education, 49, 23–28. doi:10.3928/01484834-20090828-08 [CrossRef]
  • Hotchkiss, M.A., Biddle, C. & Fallacaro, M. (2002). Assessing the authenticity of the human patient experience in anesthesiology. American Association of Nurse Anesthetists Journal, 70, 470–473.
  • Kaakinen, J. & Arwood, E. (2009). Systematic review of nursing simulation literature for use of learning theory. International Journal of Nursing Education Scholarship, 6(1), Article 16. doi:10.2202/1548-923X.1688 [CrossRef]
  • Kruglikova, I., Grantcharov, T.P., Drewes, A.M. & Funch-Jensen, P. (2010). Assessment of early learning curves among nurses and physicians using a high-fidelity virtual-reality colonoscopy simulator. Surgical Endoscopy, 24, 366–370. doi:10.1007/s00464-009-0555-7 [CrossRef]
  • Lajoie, S.P. (2005). Extending the scaffolding metaphor. Instructional Science, 33, 541–557. doi:10.1007/s11251-005-1279-2 [CrossRef]
  • Lajoie, S.P. & Lesgold, A. (1992). Dynamic assessment of proficiency for solving procedural knowledge tasks. Educational Psychologist, 27, 365–384. doi:10.1207/s15326985ep2703_6 [CrossRef]
  • Lantoff, J.P. (2009). Dynamic assessment: The dialectic integration of instruction and assessment. Language Teaching: Surveys and Studies, 42, 355–368. doi:10.1017/S0261444808005569 [CrossRef]
  • Lasater, K. (2007). High-fidelity simulation and the development of clinical judgment: Students’ experiences. Journal of Nursing Education, 46, 269–276.
  • Lave, J. & Wenger, E. (2002). Legitimate peripheral participation in communities of practice. In Lea, M.R. & Nicoll, K. (Eds.), Distributed Learning: Social and cultural approaches to practice (pp. 56–63). New York, NY: Routledge Falmer.
  • Leigh, G. & Hurst, H. (2008). We have a high-fidelity simulator, now what? Making the most of simulators. International Journal of Nursing Education Scholarship, 5(1), Article 33. doi:10.2202/1548-923X.1561 [CrossRef]
  • Leigh, G.T. (2008). High-fidelity patient simulation and nursing students’ self-efficacy: A review of the literature. International Journal of Nursing Education Scholarship, 5(1), Article 37. doi:10.2202/1548-923X.1613 [CrossRef]
  • Leonard, B., Shuhaibar, E. & Chen, R. (2010). Nursing students perceptions of intraprofessional team education using high-fidelity simulation. Journal of Nursing Education, 49, 628–631. doi:10.3928/01484834-20100730-06 [CrossRef]
  • Levett-Jones, T., Lapkin, S., Hoffman, K., Arthur, C. & Roche, J. (2011). Examining the impact of high and medium fidelity simulation experiences on nursing students’ knowledge acquisition. Nurse Education in Practice, 11, 380–383. doi:10.1016/j.nepr.2011.03.014 [CrossRef]
  • Lundberg, K.M. (2008). Promoting self-confidence in clinical nursing students. Nurse Educator, 33, 86–89. doi:10.1097/01.NNE.0000299512.78270.d0 [CrossRef]
  • McCann, T. & Clark, E. (2003a). Grounded theory in nursing research: Part 1: Methodology. Nurse Researcher, 11(2), 7–18.
  • McCann, T. & Clark, E. (2003b). Grounded theory in nursing research: Part 2: Critique. Nurse Researcher, 11(2), 19–28.
  • Mezirow, J. (1994). Understanding transformative theory. Adult Education Quarterly, 44, 222–232. doi:10.1177/074171369404400403 [CrossRef]
  • Mezirow, J. (1995). Transformation theory of adult learning. In Welton, M.R. (Ed.), In defense of the lifeworld (pp. 39–70). New York, NY: SUNY Press.
  • Milliken, P.J. & Schreiber, R.S. (2001). Constructing and deconstructing: Grounded theory in a postmodern world. In Schreiber, R. & Stern, P.N. (Eds.), Using grounded theory in nursing (pp. 35–54). New York, NY: Springer.
  • Morse, J.M. (2001). Situating grounded theory within qualitative inquiry. In Schreiber, R. & Stern, P.N. (Eds.), Using grounded theory in nursing (pp. 1–16). New York, NY: Springer.
  • Mould, J., White, H. & Gallagher, R. (2011). Evaluation of a critical care simulation series for undergraduate nursing students. Contemporary Nurse, 38, 180–190. doi:10.5172/conu.2011.38.1-2.180 [CrossRef]
  • Murray, C., Grant, M.J., Howarth, M.L. & Leigh, J. (2008). The use of simulation as a teaching and learning approach to support practice learning. Nurse Education in Practice, 8, 5–8. doi:10.1016/j.nepr.2007.08.001 [CrossRef]
  • Nehring, W.M. (2008). U.S. boards of nursing and the use of high-fidelity patient simulators in nursing education. Journal of Professional Nursing, 24, 109–117. doi:10.1016/j.profnurs.2007.06.027 [CrossRef]
  • Pardue, K., Tagliareni, M., Valiga, T., Davison-Price, M. & Orehowsky, S. (2005). Substantive innovation in nursing education: Shifting the emphasis from content coverage to student learning. Nursing Education Perspectives, 26, 55–57.
  • Parker, B.C. & Myrick, F. (2009). A critical examination of high-fidelity human patient simulation within the context of nursing pedagogy. Nurse Education Today, 29, 322–329. doi:10.1016/j.nedt.2008.10.012 [CrossRef]
  • Parker, B.C. & Myrick, F. (2010). Transformative learning as a context for human patient simulation. Journal of Nursing Education, 49, 326–332. doi:10.3928/01484834-20100224-02 [CrossRef]
  • Perkins, G.D. (2007). Simulation in resuscitation training. Resuscitation, 73, 202–211. doi:10.1016/j.resuscitation.2007.01.005 [CrossRef]
  • Ravert, P. (2002). An integrative review of computer-based simulation in the education process. Computers, Informatics, Nursing, 20, 202–208. doi:10.1097/00024665-200209000-00013 [CrossRef]
  • Reid-Searl, K., Eaton, A., Vieth, L. & Happell, B. (2011). The educator inside the patient: Students’ insights into the use of high fidelity silicone patient simulation. Journal of Clinical Nursing, 20, 2752–2760. doi:10.1111/j.1365-2702.2011.03795.x [CrossRef]
  • Rourke, L., Schmidt, M. & Garga, N. (2010). Theory-based research of high fidelity simulation use in nursing education: A review of the literature. International Journal of Nursing Education Scholarship, 7(1), Article 11. doi:10.2202/1548-923X.1965 [CrossRef]
  • Schreiber, R.S. (2001). The “how to” of grounded theory: Avoiding the pitfalls. In Schreiber, R. & Stern, P.N. (Eds.), Using grounded theory in nursing (pp. 55–84). New York, NY: Springer.
  • Smith-Stoner, M. & Hand, M.W. (2008). A criminal trial simulation: Pathway to transformative learning. Nurse Educator, 33, 118–121. doi:10.1097/01.NNE.0000312180.90400.85 [CrossRef]
  • Stone, C.A. (1998). The metaphor of scaffolding: Its utility for the field of learning disabilities. The Journal of Learning Disabilities, 31, 344–364. doi:10.1177/002221949803100404 [CrossRef]
  • Tinsley, R. & Lebak, K. (2009). Expanding the zone of reflective capacity: Taking separate journeys together. Networks, 11(2), 1–12. Retrieved from
  • Vygotsky, L.S. (1978). Mind in society: The development of higher psychological processes (, Trans.). Cambridge, MA: Harvard University Press.
  • Walker, D. & Myrick, F. (2006). Grounded theory: An exploration of process and procedure. Qualitative Health Research, 16, 547–559. doi:10.1177/1049732305285972 [CrossRef]
  • Wuest, J. (2007). Grounded theory: The method. In Munhall, P.L. (Ed.), Nursing research: A qualitative perspective (4th ed., pp. 239–271). Sudbury, MA: Jones and Bartlett.
  • Wuest, J. & Stern, P.N. (1990). Childhood otis media: The family’s endless quest for relief. Issues in Comprehensive Pediatric Nursing, 13, 25–29. doi:10.3109/01460869009009743 [CrossRef]

Dr. Parker is Faculty, Faculty of Health and Community Studies, Grant MacEwan University, Ponoka; and Dr. Myrick is Professor and Associate Dean, Teaching & Learning, Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Brian Corey Parker, PhD, RN, Faculty, Faculty of Health and Community Studies, Psychiatric Nursing Program, Grant MacEwan University, Dave Russell Education Complex, Centennial Centre for Mental Health and Brain Injury, Box 1000, Ponoka, Alberta T4J 1R8, Canada; e-mail:


Sign up to receive

Journal E-contents