Journal of Nursing Education

Major Article 

Simulation Learning and Transfer in Undergraduate Nursing Education: A Grounded Theory Study

David A. Miles, PhD, CRNA, APN

Abstract

Background:

Experiential learning through simulation allows students to improve their cognitive, affective, and psychomotor skills. Yet, the process of how simulation learning transfers to clinical learning remains unanswered.

Method:

The classical grounded theory method was used to conceptualize the process by which simulation learning transfers to the clinical environment.

Results:

A model emerged that explained the simulation learning transfer process. The core category was Acting Like a Nurse and the model had 10 categories. The beginning stages of the model included the categories: Being in Simulation and Being in Clinical. The middle stages of the model reflected interaction between the student and the simulation experience, and included the categories Being Able to Practice, Getting Feedback, Making Sense of My Learning, Fitting Together, and Applying My Learning. The final stages of the model were Gaining Confidence and Becoming More Comfortable, with the outcome category Knowing What to Do.

Conclusion:

Simulation learning enhanced transfer of learning, specifically allowing students to take on the role behaviors of what will be expected of them as a practicing nurse. [J Nurs Educ. 2018;57(6):347–353.]

Abstract

Background:

Experiential learning through simulation allows students to improve their cognitive, affective, and psychomotor skills. Yet, the process of how simulation learning transfers to clinical learning remains unanswered.

Method:

The classical grounded theory method was used to conceptualize the process by which simulation learning transfers to the clinical environment.

Results:

A model emerged that explained the simulation learning transfer process. The core category was Acting Like a Nurse and the model had 10 categories. The beginning stages of the model included the categories: Being in Simulation and Being in Clinical. The middle stages of the model reflected interaction between the student and the simulation experience, and included the categories Being Able to Practice, Getting Feedback, Making Sense of My Learning, Fitting Together, and Applying My Learning. The final stages of the model were Gaining Confidence and Becoming More Comfortable, with the outcome category Knowing What to Do.

Conclusion:

Simulation learning enhanced transfer of learning, specifically allowing students to take on the role behaviors of what will be expected of them as a practicing nurse. [J Nurs Educ. 2018;57(6):347–353.]

The clinical challenges faced by graduate nurses can be overwhelming. To help students address these challenges with greater skill and confidence, schools of nursing provided experiential learning through simulated experiences. Simulation allows students to experience patient care situations never or rarely encountered in the clinical setting. The National Council of State Boards of Nursing longitudinal simulation study (Hayden, Smiley, Alexander, Kardong-Edgren, & Jeffries, 2014) explored simulation learning as a substitution for clinical time and concluded that substituting simulation experiences for up to 50% of traditional clinical hours produced comparable readiness for practice and end-of-program educational outcomes.

Nurse educators need to use varied educational resources to enhance the development of problem solving and critical thinking skills in undergraduate nursing students (Jeffries, 2007, 2012; Jeffries, Rodgers, & Adamson, 2015). Transfer of learning is essential in this development because transfer is the core of problem solving, creative thinking, and other higher mental processes, and transfer provides a basis to facilitate new learning (Hunter, 1971).

Transfer of learning is the key to effective instruction and learning (Leberman, McDonald, & Doyle, 2006), and a deeper understanding of learning transfer is required to optimize teaching strategies, such as the use of simulation (Felver et al., 2010; National League for Nursing, 2010). A fundamental goal of education and transfer involves the influence of prior learning experiences on attempts to solve problems in new situations (Marini & Genereux, 1995). Germane to practice professions is transfer of learning where learning must be applied in meeting client needs; thus, from a standpoint of using simulation in nursing education, it is important that learning through simulation provides the student with the ability to solve problems in new situations (Rutherford-Hemming, 2012).

Given the significant human and capital resources that accompany the use of simulation, it is important to ensure that those investments are meeting educational needs, such as the transfer of learning from simulation to the practice of nursing.

A common theme in nursing literature is that the current educational curriculum may not be aligned with the needs of the active learner (Benner, Sutphen, Leonard, & Day, 2010; Billings & Halstead, 2016; Skiba, 2005). Active learning is encouraged through simulation activities and supports the constructivist position in student learning. Active learning is advantageous because it allows educators to overtly see students' struggles and explore misunderstandings. Simulation has the advantage of being an active approach due to learning that encourages usage of cognitive and psychomotor skills. The interactive process inherent in simulation allows active engagement of students, fosters discussions, and necessitates problem solving (Rogers, 2004).

Simulation may offer the advantage of fostering transfer of learning by relating theoretical knowledge to relevant clinical problems, provide a context of recall to facilitate transfer, allow students to discriminate relevant from nonrelevant knowledge, and provide a mental set useful in solving a clinical issue. In this way, the process of simulation could produce beneficial learning outcomes for undergraduate nursing students.

The Institute of Medicine's (2008) report Retooling for an Aging America: Building the Health Care Workforce determined that proper education and training would be needed to handle the needs of the expanding geriatric population. This report also asserted that educational curricula should be enhanced to demonstrate competence. Further, expectations by various stakeholders suggest a change in nursing education is needed to optimize transfer of learning, which is critical to safe and quality nursing care. This mandate then requires that nurse researchers justify the use of faculty resources and expense needed to conduct all learning activities, including simulation. An investigation into simulation learning and transfer would offer guidance on the effective integration of simulation learning in nursing education. A further understanding of why this substitution strategy produces comparable outcomes is warranted, and an investigation into transfer of simulation learning to the clinical setting would add to the body of evidence in this area.

The grounded theory method of Glaser (2001) and Glaser and Strauss (1967) was used to answer the research question, How does simulation learning transfer to the clinical setting in undergraduate, prelicensure nursing education students?

Sample

Twenty-five fourth-year nursing students participated in telephone or face-to-face semistructured interviews. The participants (23 women, two men) ranged in age from 21 to 22, years with a mean age of 21.2 years. All participants had over 3 years of college education and had completed at least one semester of a medical–surgical course and at least one clinical rotation. This nursing program admits students to the nursing program as freshmen and does not accept transfer students into the program. Students begin their nursing coursework during the freshman year. Fourth-year nursing students were purposefully sampled to ensure participants had a reference point by which to discuss their experiences with simulation learning and clinical experiences.

Ethical Considerations

The institutional review board for the university approved the study. Students were informed that they had a right to refuse to participate, they could refuse to answer any questions, and they could discontinue participation at any time without consequence. Informed consent was obtained from all students prior to the beginning of the interview and they were ensured that confidentiality would be maintained throughout and after the study.

Data Collection

Individual, semistructured interviews were conducted face-to-face in a private conference room at the university or via telephone; data collection occurred in 2014 and 2015. Twenty-five interviews were completed that lasted between 26 to 42 minutes. Interviews were digitally recorded with a cassette tape recorder as a backup. Participants were encouraged to specifically discuss their simulation learning and clinical experiences, both positive and negative. To start each interview, basic demographic information (i.e., age, work experiences, years of education completed, and number of simulation experiences) was asked as a method to establish a connection with the participant and set a conversational tone for the interview (Rubin & Rubin, 2005). Data collection commenced with an open-ended question about simulation and clinical experiences as a nursing student. An interview guide was used to help the participant focus on the simulation learning experience. After the first basic question to help the participant focus on simulation, the participants were asked about the application of simulation learning to clinical experiences. Data collection continued until no new information was yielded and emergent categories were saturated (Glaser & Strauss, 1967).

Data Analysis

Data were analyzed using the constant comparative method (Glaser & Strauss, 1967). Two levels of coding were used in the data analysis: open and axial coding. Open coding involved examination of the transcripts line by line using words, phrases, and sentences as units of analysis to identify as many codes and processes as possible. Data analyzed in each new transcript were compared with codes from previous interviews to identify similarities and variability in the codes generated. Axial coding, the second level of coding, involved clustering first-level codes into conceptual categories. Theoretical memos were recorded during the entire data collection and analysis process. Major categories emerged with properties that represented the attributes of each category and formed the foundation for the conceptual description of each category. A reduction and comparison then took place that led to significant properties of the identified categories and patterns in the data. A core category emerged that identified the basic social process as the central category related to the students' experience, with simulation learning and transfer of this learning to their clinical experiences. Theoretical memos were used to sort categories and generate descriptions of relations between categories.

Results

The category Acting Like a Nurse emerged from the data as the basic social process that captured participants assuming the role of a nurse when engaged in simulation activities. Using simulation, participants learned to prioritize, anticipate, and focus on delivering nursing care during the simulation experience. Participants then engaged in a self-evaluation process that helped them develop the ability to anticipate clinical events. Assuming the role of the nurse, as discovered from the data, were important in learning to take responsibility for a patient. Simulation was unique in that it allowed the participants the ability to do exactly what the nurse would do.

Summary of the Basic Social Process

The data indicated that the process of simulation learning and transfer to the clinical environment in undergraduate nursing students involved the students experiencing Acting Like a Nurse. The process is illustrated in the Figure.

The basic social process of simulation learning.

Figure.

The basic social process of simulation learning.

The process began with students experiencing simulation (Being in Simulation) learning and clinical (Being in Clinical) learning. Simulation learning allowed students to consistently apply information and learn how to handle clinical situations where they were often required to do everything. In contrast, clinical experiences were variable because students were in the role of a student and might not be doing, seeing, or allowed to engage in extensive patient care activities, and in at least some instances, were just observing. When engaged in simulation and clinical experiences, students were able to practice (Being Able to Practice), which could lead to them getting feedback (Getting Feedback), even though this feedback was also variable, especially in the clinical learning environment. This process of receiving student feedback allowed students to make sense of their learning (Making Sense of My Learning), where they saw aspects of their education coming together (Fitting Together) as simulation, classroom, skills laboratory, and clinical experiences all complemented each other to contribute to transfer of learning to the clinical environment. When students were able to apply their learning (Applying My Learning) material, they gained confidence (Gaining Confidence) in their ability to complete clinical work. When students consistently experienced significant learning events they gained comfort (Being More Comfortable). The outcome from simulation learning was students learning to act like a nurse and know what to do (Knowing What to Do) in various clinical situations. These categories, subcategories, and representative participant quotes are discussed in the following sections and illustrated in the Table.

Table:

Being in Simulation, and Being in Clinical

Being in Simulation and Being in Clinical represented the experiential learning activities of students in the nursing program. Being in Simulation reflected the participants engaging in simulation learning activities and doing things that they “need to know.” As participants engaged in simulation, they were learning, doing, seeing, and having things happen to them. Participants were exposed to simulation scenarios that helped them acquire knowledge and skill that was relevant to clinical practice. Participants talked about being able to make mistakes while in simulation, without “worrying about the consequences of your actions” and simulation being “a safe environment.” The other aspect of experiential learning, Being in Clinical, emerged from the data as experiences that students only experience in the clinical learning environment. During their clinical learning experiences, participants engaged in genuine patient care where they would “actually talk to a patient” and “see how that impacted them.” Clinical experiences provided participants with patient care experiences that were real and helped them gain an understanding of unique patient care situations.

Participants also described some less than optimal experiences in their clinical learning situations. Some participants spoke of spending time during which they would “stand back and watch.” These experiences did not allow participants to engage in, and take responsibility for, patient care when in some clinical rotations, although the participants could observe nursing interventions and the effect those interventions had on the patient. Participants also described clinical learning experiences where they were not doing anything.

Simulation provided a method of practice for participants to compensate for those experiences of only watching or not doing anything while in clinical learning situations. Although practice was involved in both clinical and simulation learning, the next category, Being Able to Practice, was a significant experience for participants when engaged in simulation learning.

Being Able to Practice, and Getting Feedback

Being Able to Practice emerged from the data as being allowed to engage in behaviors using simulation, prior to or after clinical learning experiences. Practice with simulation learning experiences was essential for participants to learn the necessary qualities and behaviors a nurse needs to provide safe and quality patient care.

When participants were able to practice, Getting Feedback emerged as an essential component of learning. Students received input and constructive criticism through the debriefing process in simulation. Feedback was more constructive and positive in simulation than clinical learning experiences. Participants stated, “you get more detailed feedback during simulation.”

Participants noted that feedback in clinical learning was not frequent but feedback in simulation was frequent and really helpful. Getting Feedback contributed to participants Making Sense of My Learning and Fitting Together, which are the next categories in the process.

Making Sense of My Learning, and Fitting Together

Making Sense of My Learning and Fitting Together emerged from the data as participants realized how their learning in the classroom, clinical environment, and simulation settings were complementary. Participants realized how their learning was fitting together, and this fitting together provided them with a clearer understanding of their role in patient care. Making Sense of My Learning was evident when participants engaged in simulation learning. The fit of simulation with other learning was evident, as evidenced by one participant, who stated, “simulation brought together all the pieces that we have been learning.”

Simulation and clinical learning experiences complemented each other and allowed participants to make connections between these learning experiences. Fitting together, using simulation and clinical events, resulted in situations matching up with something. Another participant, when asked about the relation between clinical and simulation learning, stated, “concepts fit together nicely. . .it did match.”

Applying My Learning

Applying My Learning emerged from the data as applying previous experience, learning, and knowledge to clinical experiences. Cognitive and psychomotor knowledge and skills acquired by participants allowed the application of these abilities to clinical problems. Transfer of learning was evident in the situation described by one participant as a phenomenon that is directly related to engagement in simulation learning. Being able to apply learning led to the participants gaining confidence and becoming more comfortable in their ability to perform patient care.

Gaining Confidence, Being More Comfortable, and Knowing What to Do

Gaining Confidence emerged from the data as participants gaining self-assurance when engaged in simulation and clinical activities. Confidence increased when participants were consistently challenged in simulation to perform at a level that demonstrated competence and they were challenged to assume the role behaviors of a practicing nurse. Gaining confidence allowed participants to become more comfortable where participants noted gaining an amount of ease and comfort when engaged in simulation and clinical learning activities. Confidence preceded comfort for participants and may not have emerged until participants acquire the ability to perform in a variety of patient care situations. Simulation allowed participants to feel comfortable engaging in the role behaviors of professional nursing practice.

Gaining Confidence and Being More Comfortable allowed participants to continue to increase the probability that they would have the ability to know what to do when confronted with situations in the patient care setting. Finally, Knowing What to Do emerged from the data as participants being able to perform in various situations, as a result of simulation and clinical learning. Participants learned what to do in simulation by being presented with the theoretical knowledge in the classroom and practicing various simulation scenarios. Participants also described the necessity of being prepared if something happens and having the knowledge to care for patients in the clinical environment. The ability of participants to acquire the knowledge and skills necessary to progress to Knowing What to Do, from simulation learning, provided participants with the ability to apply this knowledge and skill in clinical practice.

Discussion

The purpose of this study was to determine the process by which simulation learning transfers to the clinical environment in undergraduate nursing students. The results of this study, taken from a student perspective, suggest that simulation learning could transfer to the clinical environment, as students are able to take on the role behaviors of a practicing nurse during their simulation experience, which can then inform their practice in the clinical setting.

Expectations by various stakeholders suggest that a change in nursing education is needed to optimize transfer of learning, which is critical to safe and quality nursing care. The American Association of Colleges of Nursing (2008, 2009) suggested that simulation was a significant way to improve student communication and assessment abilities and was identified as a way to actively engage students in their learning. The results of this study demonstrate that simulation learning is an active engagement strategy for student learning. The finding that students can take on the role behaviors of a practicing nurse during simulation, which does not necessarily occur in the clinical setting, speaks to the benefit of simulation learning.

Jeffries (2007) and Benner et al. (2010) spoke to the benefits of simulation learning. The findings from this study, where students took on the role behaviors of the practicing nurse in simulation (Acting Like a Nurse), are consistent with Jeffries' (2007) support of simulation as a means to work with authentic problems, synthesize data, and make good clinical decisions in patient care situations. The understanding that comes from simulation where students take on the role behaviors of a practicing nurse, support the work of Benner et al. (2010), who asserted that students develop patient care skills and an understanding of significant clinical issues in simulation learning.

The National Council of State Boards of Nursing's study by Hayden et al. (2014) and the National League for Nursing-sponsored study by Jeffries (2007) are often cited evidence that support simulation learning. Nursing students' engagement in simulation has been presented as comparable to clinical learning rotations and beneficial to the process of learning, producing comparable outcomes. The findings from this study begin to inform that mechanism by which these comparable outcomes may be occurring. Just as there is variability in clinical learning experiences, there can be variability in simulation learning experiences. Wholesale substitution of clinical learning experiences with simulation is not warranted, unless the substance and quality of the simulation learning experiences is attended to. The findings of this study, where students were able to practice the role behaviors of a professional nurse, may provide some guidance for the development of scenarios for simulation learning experiences. The findings from this study may also begin to inform the why and how of simulation learning producing comparable outcomes to clinical learning experiences. There may be a need to have some leveling of simulation experiences within a nursing education program, starting with more limited simulation experiences early in the program of study. As students gain experience from their clinical learning and gain additional knowledge through their classroom learning, then perhaps more simulation experiences can be used in later stages of their program, as they move toward program completion and graduation and closer to assuming the role of the professional nurse. This leveling of simulation experiences is an area for further study.

Credibility of the Theory

Glaser and Strauss (1967) presented recommendations for conveying credibility of a grounded theory work based on explanation of the coding, analysis and presentation of data, and the way that readers understand the theory. The theory presented in this research has beginning, middle, and end phases, which suggests a completeness to the theory. Students engaged in clinical learning and simulation learning in the early phases, which then provided more details on the processes that occur as they learn to take on the role behaviors of the professional nurse. The end-point of this theory of simulation learning and transfer is knowing what to do in patient care situations; thus, the theory presented here is a complete theory, which is one of the criteria put forth by Glaser and Strauss (1967) to judge the credibility of the theory. Glaser and Strauss (1967) also referred to using specific procedures for analyzing data as a method of establishing credibility of the theory. The procedures for obtaining and analyzing the data in this study provide a description of how those data informed the conceptualization of the categories of the theory. Using the constant comparison approach, codes were generated from the data and integrated into theoretical categories, and the properties of those categories were identified. The use of theoretical memos during the data collection and analysis phases of this work provided insights into the basic social process emerging from the data, which then further informed the sequencing of the categories of the theory and the delimiting of the theory.

Limitations

A limitation of this study is that the sample was only composed of 4-year baccalaureate nursing students and did not include accelerated baccalaureate, associate degree, or transfer nursing students. These students may have different experiences in simulation, as each program may use simulation differently, such as for evaluation rather than teaching, which was the practice in this study site. In addition, the quality and subject matter of simulations will vary across sites, which could also affect these findings.

Conclusion

The process of simulation learning and transfer to the clinical environment is an important issue in nursing education. The results of this study provide a conceptualization to provide some guidance in the effective and targeted use of simulation educational resources.

The model that emerged from the data identified the process by which simulation learning transfers to the clinical environment in undergraduate nursing students. This model demonstrates the value of experiential learning through simulation in the transfer of relevant knowledge and skill to challenging clinical problems and to developing the role behaviors of the professional nurse in nursing students.

The findings of this study have implications for nursing practice, education, and future research. Simulation learning could help bridge the gap between nursing education programs and clinical practice. New graduate nurses that are involved in targeted simulation learning may transition better into clinical practice. The emerging theory is useful for nurse educators to understand the process that simulation learning transfers to the clinical environment. Nurse educators can also facilitate student learning and professional development by using the study model when connecting classroom, clinical, and simulation learning. Simulation learning, integrated in a nurse residency program, may better prepare graduates for clinical practice. The ability to be in charge and assume complete responsibility for the patient, specifically acting like a nurse, while engaged in clinical practice, may reduce the orientation period for new graduates, enhance confidence, and provide stability in the clinical setting. Readiness for practice could also be enhanced with simulation learning and contribute to new graduates integrating the nursing process, critical thinking, and developing a mental checklist of significant clinical tasks; these are areas of further study.

The results of this study indicate the need to further study simulation learning and the process of transfer in various student groups to confirm or modify the model. It is anticipated that the educational strategy of simulation learning will continue to become an important part of nursing and medical education. Measures should be developed to operationalize the categories of the theory, with further testing of the theory using quantitative approaches. The results from this study provide some support for the use of human and capital resources dedicated to simulation learning in nursing education and support for simulation learning as a beneficial component of undergraduate nursing education.

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Category/SubcategoryParticipant Quotes
Acting Like a Nurse“Exactly what the nurse would do.”
“It gives us a nurse and do things like the nurse would do.”
“I actually had the opportunity to do what the nurse would do in that situation.”
“It will show us what could happen and what the role of the nurse is.”
“It allows us more of an opportunity to be independent and in the role of the nurse.”
Being in Simulation
  Experiencing things“Situations we might be in and not be in during clinical days. I have another chance to get it right.”
“Very relevant, we go over exactly what we would be experiencing in that field.”
“It was very good mostly because we were in situations that we might not be in during our clinical days.”
  Being able to make mistakes“Much more hands on; we are not worrying about the consequences of our actions.”
  Being in a safe environment“Prefer to make mistakes on manikins. It is okay to mess up. It is one of those safe places.”
Being in Clinical
  Experiencing it for real“Actually talk to a patient and see how it impacted them.”
“Don't get a sense of heartbreak until you are there.”
“It has more depth, a real person and setting to do.”
“Real life people are always different.”
  Only observing and not doing“Stand back and watch.”
“We don't get the opportunity.”
“We really don't get the chance to do very much.”
Being Able to Practice“It wasn't a real patient; I felt like I had more of an opportunity to practice it.”
“Yes, it is helpful practicing skills that we don't get to practice in clinical.”
“It is not the type of preparation you can practice without simulation.”
Getting Feedback“You get more detailed feedback during simulation.”
“In clinical they are not watching me, so I don't get much feedback.”
“Get a lot of different viewpoints of what you could have done better.”
Making Sense of My Learning“Make sense of what is happening.”
“It all came together in the end.”
“I would have known what they would have done in the room.”
Fitting Together“Simulation brought together all the pieces that we have been learning.”
“Matching up with something; even different concepts fit together nicely.”
“They complement each other because what we are learning in simulation is completely relevant.”
Applying My Learning“I take that information out of my head and apply it.”
“It's about you understanding and being able to apply what you learned.”
“I am able to transfer over this to what I am doing in simulation and this is what I am doing for my patient.”
Gaining Confidence“I am confident I would know what to do.”
“Confident enough to perform.”
“That is very helpful in boosting my confidence.”
Being More Comfortable“It helps me more comfortable with a particular patient.”
“It definitely grows as you get more comfortable throughout the semester.”
Knowing What to Do“Very helpful to gain that knowledge from [simulation].”
“I know what I am doing, where I am going and how I will handle the situation.”
“We all know what to do; like we studied exactly what to do.”
Authors

Dr. Miles is Clinical Instructor and Educator, Anesthesiology, Methodist Hospitals, Merrillville, Indiana.

The author has disclosed no potential conflicts of interest, financial or otherwise.

The author thanks his dissertation committee—Dr. Lee Schmidt, Chairperson, and committee members Dr. Nancy Hogan, Dr. Barbara Velsor-Friedrich, and Dr. Leann Horsley—for their expertise and dedication to this work.

Address correspondence to David A. Miles, PhD, CRNA, APN, 20544 Hickory Ct., Frankfort, IL 60423; e-mail: dave_miles@sbcglobal.net.

Received: May 22, 2017
Accepted: February 21, 2018

10.3928/01484834-20180522-05

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