Contemporary simulation activities within highly authentic environments are popular learning strategies across health care professions at the undergraduate level and for continuing professional development. For undergraduate students, a common aim of simulation is to provide a holistic learning opportunity, which merges theory with clinical practice perspectives, often providing insight into the professional role and expected behaviors (McGrath, Lyng, & Hourican, 2012; Ricketts, 2011). The importance of teamwork and effective communication are other aims frequently included as simulation learning outcomes (Laschinger et al., 2008; Miller, Riley, Davis, & Hansen, 2008). Much literature supports these foci as important objectives for simulation learning encounters (McGaghie, Issenberg, Petrusa, & Scalese, 2010; Neill & Wotton, 2011; Schlairet, 2011). However, despite best intentions, there may be a mismatch between the planned benefits, participants’ perceptions of learning, and learning outcomes following the simulation encounter.
Much time and effort are expended when creating simulation encounters to achieve the aforementioned aims. In a systematic review of 12 selected studies, Cant and Cooper (2010) summarized core components included in effective simulations as briefing and orientation to the environment and simulator, the simulation activity, and a debriefing session. These are considered the minimal elements to provide a safe, meaningful simulation learning encounter (Arthur, Levett-Jones, & Kable, 2013; Jeffries, 2007; Waxman, 2010). Including a skill review session prior to the simulation is another commonly practiced activity (Rochester et al., 2012), but there are other variations in and around the preparation for, and guidance during and following, the simulation encounter (Cant & Cooper, 2010). Variation in itself should not be perceived as problematic but responsive to participants’ specific learning needs. However, what remains unclear is the participant’s or student’s perceived benefits to their learning from the varied components of a simulation encounter.
In early work by Jeffries (2007), a range of simulation evaluation instruments were created, specifically the Simulation Design Scale, Educational Practices in Simulation Scale, and Student Satisfaction and Self-Confidence in Learning Instrument. Although these measures have been validated and used in subsequent studies (Kardong-Edgren, Adamson, & Fitzgerald, 2010; Reese, Jeffries, & Engum, 2010), other aspects of simulation delivery or the relationship of learning to clinical judgment are not overt within these and other instruments. Another recently developed measure, the Satisfaction with Simulation Experience Scale (Levett-Jones et al., 2011), connects aspects of the simulation (the facilitator, debriefing, reflection) to clinical reasoning but remains generic and does not include the full array of simulation components used across other settings. Further, few studies focus on the relative value of components of a simulation encounter for learners from varied backgrounds. Therefore, the main aim of this study was to investigate the contribution of 11 specific simulation components to the enhancement of clinical judgment for students from three different study streams within an undergraduate nursing program.
Theoretical Framework for Clinical Judgment
At one large Australian university, simulation has been fully integrated into the renewed Bachelor of Nursing (BN) program. One theoretical framework embedded across the BN courses and related simulations is Tanner’s (2006) model of clinical judgment. The model comprises four discrete aspects, which represent how expert nurses think when engaging in patient care. The aspects of noticing, interpreting, responding, and reflecting provide a schema for less experienced nurses to understand and develop their practice and for educators to use as a scaffold for teaching and learning. Key to students’ understanding and prioritizing patient care requirements is honing their skills in noticing. What students bring to the patient care situation is based on prior exposure to similar scenarios and expectations of what might unfold, underpinned by theoretical knowledge and life experiences (Tanner, 2006). Simulations are one way to provide students with exposure to patient care scenarios to contribute to noticing and clinical judgment.
During the past 5 years, a deteriorating patient simulation has been included within a clinically focused medical–surgical course in the final year of the BN program. This simulation provides an opportunity for students nearing the end of their degree to engage in an authentic postoperative surgical scenario and to interact with a patient, relative, and other team members. Students are given an opportunity to assess (notice) the clinical situation (decreased urine output and oxygen saturations with increased breathlessness), determine appropriate actions within the context of the scenario and information available (interpret), and communicate with senior colleagues in response to the patient’s deteriorating condition (respond).
The format of the simulation followed Jeffries’ (2007) recommendations and included a briefing and orientation to the simulation environment, the simulation activity, and postsimulation debriefing. Additional components were online access to patient case information 1 week prior to the simulation, specific questions for student observers to contribute to the debriefing session, and the possibility for guidance by the academic during the simulation. A second academic resided in a separate control room and provided patient responses via the manikin’s speaker. This design and level of support were selected as the faculty were in the early stages of implementing contemporary simulations, and this was the first such experience for many of the students.
During one of the weekly clinical laboratory sessions, five to six students actively participated in a simulation role while five or six remaining students observed the first phase of the patient scenario. On conclusion of the first phase, student observers changed roles and actively participated in the second phase while their peers became observers. The two phases represented two time points of the same patient case. The simulation ran for approximately 10 minutes and was followed by a 20-minute debriefing session facilitated by the academic. A postsimulation survey was then used to gain students’ insight about their learning experiences in relation to clinical judgment.
This is a quantitative descriptive study that examined nursing students’ ratings of simulation components that contributed to clinical judgment. Subsequent to participation in the deteriorating patient simulation encounter described above, a convenience sample of final-year students from six classes over 2 years (N = 150) was asked to participate in the research by completing a survey.
This study was granted approval by the university’s human research ethics committee. All students participated in the simulation as part of the respective course offering, and those who agreed to engage in the research did so voluntarily. Students were aware there was no course credit for participating in the research. Each participant was provided with a survey code to deidentify responses. The primary author (M.A.K.), who was not involved with teaching the respective classes, collected the data. Students could opt out of the research at any time without consequence.
Postsimulation Survey: Data Management and Analysis
Demographic data collected included age, gender, study stream, years of previous nursing experience, highest educational qualification, and number of previous simulations.
Students’ rating of the benefit of individual simulation components to their clinical judgment was assessed using a survey developed for the study by the primary and secondary authors (M.A.K. and P.H., respectively), both experts in simulation and education assessment. The survey questions addressed 11 components of the simulation determined through a literature review and based on the aspects of clinical judgment from Tanner’s (2006) model. The survey was pilot tested on 30 students, and five questions were modified. Participants were asked to rate each of 11 components of the simulation on the benefit the component had on applying clinical judgment using a 5-point Likert Scale (1 = little assistance to 5 = great assistance). Not all 11 components assessed, such as guidance by the academic, are included in all simulation activities, but students would have experienced all 11 components at some stage in the simulations during the 2 or 3 years of their study program. Students were familiar with Tanner’s model through course lectures and previous clinical laboratory sessions.
Data were analyzed using the SPSS® (version 19) computer software program. Data were summarized using frequencies and percentages for categorical data and means and standard deviations or medians and range for continuous data. Analysis of variance (ANOVA) was used to determine whether study stream (3-year, 2-year enrolled nurse, 2-year graduate entry), age, years of nursing experience, and gender influenced students’ ratings of the benefit of the different components. The significance level was set at p < 0.05.
One hundred two from a possible 150 nursing students participated in the research (response rate, 68%). The sample comprised three student groups: recent school leavers undertaking a 3-year nursing program (57%); 2-year graduate entry (GE) students (25%) who possessed a bachelor’s degree in another discipline and were making a career change to nursing, and 2-year enrolled nursing (EN) students (18%) who had completed 1 year of technical college education, had prior clinical experience, and were upgrading their qualifications.
The sample was predominantly female (82%), aged 19 to 25 years (68.9%), and had 2 or fewer years of nursing experience (63%). More than 70% of respondents had either one or no previous simulation encounters.
Simulation Component Ratings and Ranking
Participants’ ratings on the assistance that the 11 simulation components provided to clinical judgment ranged from a mean of 3.23 to 4.02 (5-point rating scale), as demonstrated in Table 1. The three simulation components that received the highest ratings for contributing to clinical judgment and mean scores above 3.7 were facilitated debriefing, postsimulation reflection, and guidance by the academic. The components rated by participants as least beneficial to clinical judgment were the patient case notes (mean = 3.23) and participating in a role (mean = 3.46).
Ranking of Students’ Ratings of the Benefit of Simulation Components to Making Clinical Judgments (N = 102)
Comparison of Rankings by Study Program
Table 2 provides the ratings students gave for the benefit of the simulation component to clinical judgment across the three student groups. The mean scores were all above 2.9, indicating that students thought all components assisted in some way. The top two ratings were the same for all groups—facilitated debriefing and postsimulation reflection—but the lowest ratings varied. The lowest rating for 3-year students was patient case notes; for 2-year EN students, the patient case scenario topic; and for 2-year GE students, participation in a role.
Rankings of Simulation Components for Each Student Group
Statistically significant differences in mean ratings occurred in two simulation component areas: in postsimulation reflection (p = 0.003) specifically, the 3-year program mean score (3.74 ± 1.05) was lower than the 2-year GE (4.58 ± 0.78). The second statistically significant difference was viewing the simulation recording (p = 0.008), with the 3-year program having a low mean (2.97 ± 1.19), compared with the 2-year GE students (4.3 ± 0.95). No other variable tested (age, years of nursing experience, or gender) had a statistically significant effect on the mean scores of simulation components.
Developing and enhancing students’ clinical decision making to form judgments about patients’ care needs is a desired outcome for all nursing programs. Simulation is one teaching and learning method to enable a holistic, active experience for students to appreciate the range of registered nurse practices and responsibilities. This study provides new insight into three unique senior nursing student groups of an expanded range of simulation components and the level of assistance each provided in applying clinical judgment.
The high value of facilitated debriefing for these students corroborates existing literature related to the value of debriefing for learning (Dreifuerst, 2009, 2011; Lusk & Fater, 2013; Mariani, Cantrell, Meakim, Prieto, & Dreifuerst, 2013) and, similarly here, for applying clinical judgment. Many would agree that postsimulation reflection commences and extends beyond the time allocated for debriefing (Dreifuerst, 2012; Shinnick, Woo, & Mentes, 2011). Reflection was highly valued and ranked second to debriefing, with statistically significant differences across two of the student groups. Reflective practice is an important professional attribute to develop (Schön, 1995; Tanner, 2006), and it appears that simulation triggers reflection during and immediately following the simulation experience.
However, the third highest rating component—guidance from the academic—is not always incorporated into the delivery of simulation activities. Practices vary in the level and manner of support provided to students during simulations and range from no academic support (neither physical presence within the simulation room nor communication by telephone), to proxy guidance through the manikin’s responses or by telephone (via the academic), to an academic physically taking on a role and actively engaging in the simulation scenario. For students who are advanced in their study program, guidance from the academic may be perceived as unnecessary. Yet, this component was rated one of the top three for assisting students to make clinical judgments, likely because the group were novices in simulation. However, irrespective of the level of theoretical knowledge and skills practice, study findings support that students value interacting with or observing experienced teachers engaging in clinical practice learning activities, which simulation enables to a much greater degree (Aronson, Glynn, & Squires, 2013; McGrath et al., 2012). Although the study group comprised final-year nursing students, most had limited simulation experiences, so it was not surprising that despite having more knowledge, it appeared that senior students gained from the guidance provided during the simulation in applying clinical judgment.
Components rated least beneficial for clinical judgment were the patient case notes and briefing and orientation to the simulation area. Given that the survey questions were focused on clinical judgment, it is not surprising these components provided less value for students during the simulation. However, these components offer important context for learning and should always be provided, particularly for students and those new to simulation. Although data about viewing the simulation audiovisual playback were collected for 1 year only, marked contrast exists across student groups for this component. The perceived value of viewing the audiovisual playback (Chronister & Brown, 2012) may vary depending on the student cohort, as the 2-year GE group had much higher mean scores compared with the two other groups.
The findings from this ranking exercise are useful in that the student’s perspective of what is considered important in their learning and application of clinical judgment becomes clearer, rather than what academics assume may be of most value within simulation activities. The key insights from these data are that students value facilitated debriefing, reflection, and guidance by the experienced academic for assisting with clinical judgment. Although differences emerged of the relative value of components across the three groups, above average ratings for all components indicated benefit for these students. Further, it appears that regardless of age, years of nursing experience, or gender, simulation is similarly beneficial for clinical judgment across different student cohorts therefore tailoring is not necessary.
Study Strengths and Limitations
These findings have not been reported previously in the literature and provide a valuable perspective from both pedagogical and operational perspectives to consider when developing and delivering simulations. The response rate of 68% provides a reasonable representation of the majority opinion, but a higher rate would be desirable. The survey requires use in different populations to determine psychometric properties. Self-report as a single level of inquiry has limitations in reliability related to social desirability. Although the survey was conducted on the same day as the simulation, groups crossed over from participation to observer roles and would have had an opportunity to begin to reflect on their own and others’ practice. Study findings therefore report immediate impressions and early perceptions of the postsimulation reflective process. Data obtained from multi-site, rather than single-site, institutions would provide more generalizable findings.
Opinions from students with varying backgrounds about the components that matter most shed new light for simulation practice in relation to application of clinical judgment. Irrespective of the entry level or program of study, this student population rated all 11 simulation components useful in applying clinical judgment. Tanner’s (2006) model provides a scholarly framework for curricula, simulations, and enhancing students’ clinical judgment for nursing practice.
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Ranking of Students’ Ratings of the Benefit of Simulation Components to Making Clinical Judgments (N = 102)
|Ranking||Simulation Component||Mean (SD)|
|1||Facilitated debriefing||4.02 (1.03)|
|2||Postsimulation reflection||3.98 (1.03)|
|3||Guidance by the academic||3.78 (1.1)|
|4||Observing others and making notes||3.65 (1.07)|
|5||Participation in the simulation||3.60 (1.04)|
|6||Asking questions of the patient, family, and others||3.54 (1.04)|
|7||The patient case scenario topic||3.48 (1.15)|
|8||Briefing and orientation to the simulation area||3.48 (1.19)|
|9||Participation in a role||3.46 (1.14)|
|10||Viewing the simulation audiovisual playback||3.33 (1.22)a|
|11||Patient case notes||3.23 (1.27)|
Rankings of Simulation Components for Each Student Group
|Simulation Component||Study Stream Within Bachelor of Nursing|
|3-Year||2-Year EN||2-Year GE|
|Rank||Mean (SD)||Rank||Mean (SD)||Rank||Mean (SD)|
|Facilitated debriefing||1||3.83 (1.08)||1||4.10 (0.93)||2||4.40 (0.91)|
|Postsimulation reflection||2||3.74 (1.05)||2||3.95 (1.03)||1||4.58 (0.78)*|
|Guidance from the academic||3||3.66 (1.10)||5||3.63 (1.26)||4||4.20 (0.91)|
|Participation in the simulation encounter||4||3.60 (0.99)||7||3.53 (1.02)||8||3.60 (1.23)|
|Participation in a role||5||3.46 (1.05)||5||3.58 (1.07)||11||3.28 (1.4)|
|Observing others and making notes||6||3.41 (1.09)||2||3.95 (0.84)||5||3.96 (1.06)|
|Asking questions of the patient, family, and others||6||3.41 (1.06)||4||3.84 (0.83)||8||3.60 (1.16)|
|Patient case scenario topic||8||3.33 (1.01)||11||3.22 (1.26)||5||3.96 (1.14)|
|Briefing and orientation to the simulation area||9||3.26 (1.18)||7||3.53 (1.07)||7||3.88 (1.27)|
|Viewing the simulation audiovisual playback||10||2.97 (1.19)||10||3.46 (1.20)||3||4.30 (0.95)*|
|Patient case notes||11||2.96 (1.30)||7||3.53 (1.26)||10||3.56 (1.26)|
|Total mean (SD)||3.42 (0.28)||3.66 (0.26)||3.94 (0.4)|
|Range||2.96 to 3.83||3.22 to 4.1||3.28 to 4.58|