simulation training in nursing education

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Simulation in Clinical Nursing Education

Konstantinos koukourikos.

1 Nursing Department, Alexander Campus, International Hellenic University, Thessaloniki, Greece

2 Nursing Department, University of Peloponnese, Tripoli, Greece

Areti Tsaloglidou

Lambrini kourkouta, ioanna v papathanasiou.

3 Nursing Department, University of Thessaly, Larissa, Greece

Christos Iliadis

4 Private Health Center of Thessaloniki, Greece

Aikaterini Fratzana

5 “G. Papanikolaou” General Hospital of Thessaloniki, Thessaloniki, Greece

Aspasia Panagiotou

Background:.

Simulation constitutes a teaching method and a strategy for learning and understanding theoretical knowledge and skills in the nursing and medical field.

To review and present modern data related to this issue.

Literature review of data related to the issue derived from Medline, Cinhal, and Scopus databases, in English, using the following keywords: nursing, simulation, simulator, nursing laboratory.

The implementation of simulation enables students to practice their clinical and decision-making skills for some significant issues they may face in their daily work. The protected environment and the sense of security enhance students’ self-esteem and confidence, thus promoting learning. In this way, the gap between theory and practice is substantially reduced.

Conclusion:

The further development of simulation, along with other instructional techniques, can significantly help the efforts made by the students to become integrated and successful healthcare professionals.

1. INTRODUCTION

One of the major problems of nursing education is the lack of coordination between theory and practice. Nursing students encounter difficulties in the practical implementation of theoretical knowledge and this is a problem seen on an international scale ( 1 , 2 ). The distance created between theory and practice complicates the learning process and the lack of understanding of nursing terms and concepts affects the professional integration of a student ( 3 ). This is achieved through real knowledge and understanding of healthcare science, where nursing theory is harmoniously combined with practical skills. A teaching technique contributing to this direction is simulation.

Simulation is defined as “the process by which we are trying to achieve results approximating clinical practice as closely as possible”. It is a technique for replacing or completing real-life experiences with guided experiences, which area faithful imitation of the real world in a fully interactive way ( 4 ). It is a teaching method where, following a certain scenario, students experience the actual dimensions of their future professional roles, which helps them to be more quickly integrated into the workforce of the healthcare sector ( 5 , 6 )

In nursing science, simulation is used for teaching theoretical and clinical skills, while focusing on the promotion of the critical thinking of students ( 7 , 8 ). Simulation enables students to work in an environment closely resembling that of a hospital and helps them to gain healthcare and nursing experiences, even before they start working as professionals. The students are able to put everything they have been taught into practice, cope with any difficulties and problems, and even make mistakes without causing damage, and all that in a safe environment, without any risk whatsoever for patients ( 9 , 10 ). An increase in the use of simulation is due to the lack of clinical structures for student training, lack of professors, and also due to the increased quality of training provided through this method ( 11 ).

2. OBJECTIVE

The aim of this study was to review and present modern data related to this issue.

3. METHODOLOGY

This is descriptive study based on searched and used literature data related to the issue derived from on-line databases: Medline, Cinhal, and Scopus (in English), using the following keywords: nursing, simulation, simulator, nursing laboratory.

4. RESULTS AND DISCUSSION

Simulation-based learning.

Simulation constitutes a teaching and training technique for healthcare professionals aiming at the substantial understanding, enhancement and dissemination of knowledge, skills and attitudes of healthcare professionals at all levels. Through this technique, students experience an actual hospital setting and interact in it, thus significantly reducing the probability of errors in the performance of their duties ( 4 , 12 ).

Simulation-based education and learning is an answer to the mainly theoretical training of students to date and helps them to develop knowledge, skills and attitudes, while creating a sense of security both for the patient and for the healthcare professional ( 13 ). This technique rebuilds a skill or clinical experience, in full or in part, without exposing the patients to any risk whatsoever ( 14 , 15 ). It is used for applying structured learning experiences (e.g., venipuncture, patient resuscitation) based on a certain action protocol, and for enhancing the team spirit and spirit of cooperation, mostly in countries with limited educational resources ( 16 , 17 ). This technique minimizes errors, increases the satisfaction of students from the educational process, and enhances their self-confidence, self-esteem, and comfort in skill performance. Now, the students are familiar with the successive steps required to acquire a skill, perfect their technique, and reach the optimal clinical outcome. Simulation-based education and learning becomes interactive and experiential, the main benefit being the consolidation of skills acquired and knowledge taught ( 18 - 20 ). The setting where the simulation is performed promotes learning and, through the repetition of a skill, this skill becomes fully understood and clear. In their work Wellard et al. ( 21 ) report that the protected setting of a laboratory practically drives students to learn and understand certain skills, while Freeth et al. ( 22 ) argue that clinical laboratories and simulation substantially reduce student anxiety and fear. By choosing rare or unusual examples or scenarios, a student becomes acquainted with a wide range of interventions and skills, thus enhancing the effectiveness of education ( 23 ). In a research by Croxon et al. ( 24 ) the students made positive comments and strongly argued that simulation and the clinical laboratory procedure have prepared them for what they will later face in the hospital.

The basic nursing skills including intramuscular and intravenous drug administration, venipuncture, nasogastric catheter placement, colostomy care, bladder catheterization, oxygen therapy, and basic life support lessons can be taught by the use of simulation.

Another basic parameter of simulation is the possibility of assessing student performance, since the step-by-step learning of a skill allows repetition and testing thereof ( 25 ).

Simulation Types in Nursing Education

Through the use of simulation, an attempt is made to replace real patients with virtual standardized patients, or technologies and methods capable of reproducing actual clinical scenarios for therapeutic and educational purposes. These processes include, among others, plain demonstration of a certain scenario on a computer (cognitive test), simulation of a nursing skill, or carrying out of an integrated process. The basic types of simulation in nursing education include the following ( 15 , 25 , 26 , 27 ):

Use of high-fidelity mannequins or technologies.

These constitute body blocks or body part blocks with characteristics of life, which can respond to actions or interventions by the students. They are used for representing the clinical reactions-symptoms of a patient and for describing any conditions surrounding a case, for example, tool stocks available (e.g., dressings, syringes, etc.) and time limits available.

Low-fidelity mannequins.

Use of low-fidelity mannequins capable of performing a small number of particular tasks or processes, for example, a limb for catheterization of a vessel, or mannequin for CPR learning.

Partial task simulators.

This category includes models (e.g., hands-arms) used for implementing a clinical skill-task that may be repeated by students. Typical examples include “limbs” for intravenous catheterization of a vessel, head and chest mannequins for placing an airway and faux leather cushions for practicing wound suturing.

Virtual reality. Virtual reality is increasingly being adopted as a simulation tool. In health professions, the simulation of virtual reality uses computers and standardized patients to create a realistic learning and evaluation setting.

Standardized patients - Volunteers playing the roles of patients.

These are trainees behaving in a particular way for realistic clinical interactions. They are widely used for teaching and assessment in nursing education, especially for communication purposes and for the acquisition of skills, and they may provide feedback when requested.

E learning (usually knowledge testing, e.g., multiple tests).

Computer-generated simulators are representations of tasks or settings used for facilitating learning. These include a simple computer program demonstrating the operation of a device, e.g., anesthetic machine, or something highly complicated, e.g., a detailed setting for virtual reality, where the participants interact with virtual patients or other healthcare professionals.

Hybrid Simulation.

This type of simulation is defined as a type where two or more simulation types are combined to produce a more realistic simulation experience. A typical example is the use of portable devices by standardized patients, where students are able to perform certain procedures while interacting with a real person. For example, a standardized patient may fix a suture training model (cushion) on his/her arm, where the trainee can suture a wound; thus, while giving the trainee the opportunity to obtain informed consent, explain the procedure, etc.

Benefits of patient simulation in Nursing Education

Simulation, as an evidence-based educational technique and process, firstly appeared when it became difficult for nurses working in a hospital to acquire clinical experiences. Simulation helps to address any limitations related to the clinical setting (including availability of patients, security issues etc.), promote teamwork and solidarity among students, and implementation of a protocol for the attainment of a skill. It is based on a scenario, where learning becomes interactive, allows feedback between the educator and the other members of the team, and promotes clinical reasoning and critical thinking in the team ( 28 ).

The majority of students are familiar with advanced computer technology and computer games. As a result, there is relative comfort with certain types of simulation using computers, mainly in providing audio and video feedback in real time, thus helping a student even more to perform a skill. The controlled and totally safe setting (both for the patient and for the student) of a laboratory that a professor may operate, constitutes another factor leading a student to success and knowledge. In addition, an activity may be interrupted for discussion and correction and be continued later. Video recording of a skill significantly contributes to the evaluation of an activity by both the student and the professor ( 29 ).

According to Cook et al., ( 30 ) health care systems are reinforced by simulation, because there is an interprofessional development of the team of healthcare professionals, an overall improvement in the performance of activities and health care skills, and an enhancement of the competence of healthcare professionals in a safe setting. Error analysis, discussion on communication-related issues, and missed opportunities for optimizing health care may become topics for feedback.

Simulation helps to develop different scenarios requiring the use of both clinical skills and critical thinking skills by nurses, in order to solve problems. In addition, according to Savarese ( 31 ) there is a trend towards replacing the clinical experience of the hospital with simulation programmes, even by fifty per cent, in the curricula of nursing schools.

The factors that may determine the attainment of learning outcomes and promote the self-confidence of students include the area where simulation is performed, psychosocial contact and interaction of students, organization and elements of teaching ( 32 ). Teaching focuses on students, and it is a process of experiential exercise centered on training and cooperation with others ( 33 ).

Through simulation, nursing students may practice their abilities and clinical skills, make errors that will not be fatal for the patients, and repeat the process (more than once) leading to mastery. In addition, they have time to reexamine and reflect on their performance, and reach a kind of review, which is necessary for completion of the process ( 34 , 35 ).

This process provides an opportunity for active participation of students, and it is focused on error prevention, immediate feedback, and creation of an appropriate training environment, where students will feel and actually be psychologically safe, will communicate among them, and be able to review the process. Participation in small groups allows the students to directly monitor the attempts made by their classmates, improve their methods and enhance solidarity among them ( 36 , 37 ). Simulation establishes a bridge between theory and clinical practice. Students are able to understand a skill, because they can see it and apply it on a patient simulator. Thus, critical thinking develops and clinical decision-making skills lead to substantial learning experiences ( 38 ).

It is well documented that simulation-based training helps to enhance communication skills, the ability to cooperate with other members of the interdisciplinary team, the ability to manage complex situations, and to enhance self-efficacy and understanding of interpersonal relations ( 39 , 40 ).

According to a study by Crowe et al.,( 41 ) through simulation it is possible to enhance nursing knowledge and skills, promote communication skills, and enhance confidence and self-reliance of nurses in the exercise of their duties. Therefore, this reduces their stress, makes them feel more confident, enhances their psychomotor skills, and makes them ready to apply nursing interventions in a clinical setting.

Currently, simulation-based training as an educational tool in nursing science has multiple uses. The most recent applications include continuing vocational training, just-in-time training, and development of a team spirit. Educators play a significant role in regulating the entire procedure and through their knowledge and skills, they facilitate learning. Educators also ensure that an atmosphere of psychological safety is created, in order to enable students to act in this setting, thus reducing other concerns and problems they may have ( 42 ).

Limitations on the use of simulation in Nursing Education

There is a widespread use of simulation in nursing schools and it continues to spread, since the benefits are enormous. However, there are certain limitations in the teaching of nursing skills through simulation, the most significant of which include the following:

Simulation as technique and holistic nursing care as philosophy constitute two different components of nursing courses, which have been merged in the process of acquiring knowledge and skills required for patient care. Simulation provides opportunities for acquiring and applying knowledge and skills through the use of simulators, standardized patients and virtual settings. However, it is impossible to approach a patient as a whole, as a biopsychosocial human being ( 43 ).

Another limitation of simulation training is that sometimes not all variables related to an emergency in a live environment are included. Simulation training is carried out in a controlled setting managed by the educator, who may stop and restart a process, which is impossible in real life ( 29 ).

Simulation is a process trying to resemble real life, but it is not real. Its realism depends on the fidelity of the simulator, the setting, and the description of the scenario. As advanced simulation models may be, there will always bean imperfect imitation of human systems. As well trained the students may be, whenever they are called to apply a skill in real time and conditions, they often are extremely stressed or “freeze”, being unable to successfully complete the procedure. Therefore, schools are trying to update different simulation programmes, investing in machinery, or using actors in roles of patients, in order to add plausibility in their reactions. In addition, training of professors in simulation processes and technological issues is required. As realism increases, the effectiveness of simulation and scenario as a training tool also increase ( 44 , 26 ).

Training of nurses in whatever way possible, especially if such training is achieved by means of simulation, is not a low-cost effort. The equipment and operation of a modern laboratory demand quite large expenses. Purchase of computers and high-fidelity simulation models and maintenance there require considerable funds. Amortization of such equipment will be achieved through an appropriate and rapid training of students and, consequently from the health care provided to patients by well-trained nurses ( 45 , 46 ).

Familiarization of educators with technology, in general, is a necessary condition for smooth operation of the simulation programme and appropriate training of students. Being a simulation educator is different from being a professor in a nursing school. However, such distinctions are rarely made and health educators are inadequately trained and have limited skills as a result, such training is ineffective ( 47 ).

Incomplete training is another significant limitation that may appear in simulation. A poorly designed scenario may result in negative learning. For example, if certain physical reactions are missing during the simulation process, the students may neglect them and fail to test them. Frequently, due to time constraints, simulation fails to assess some essential parameters of the health care procedure and communication. Thus, the students fail to ask for or obtain the consent of the patient to the implementation of a medical procedure, or fail to follow basic rules of communication, which are necessary for establishing personal contact and creating a healing environment ( 26 ).

The attitude of trainees is of great interest. The participants will always approach a simulator different from when they are in real life. There will be anxiety and concern, on the one hand, because one is aware that a certain event will occur and, on the other hand, one may not pay attention, because no one’s life is in danger ( 48 )

Educators and Simulation

Educators play a significant part in the successful implementation of simulation programmes. It is not assumed that a nursing professor is identified with a simulation educator. Knowledge of technology and technological applications is necessary for successfully teaching the parameters of nursing science. A study by Simes et al., ( 49 ) aiming at investigating the factors affecting the comfort of simulation educators in an Australian university, reported that there are four factors affecting educators: 1. Personal Barriers (including excessive stress from students’ expectations), 2. Structural Barriers (including understanding of educational material, access to teaching and learning resources), 3. Human Resource Barriers (e.g., when there is no prior information and discussion on simulation programmes, and the students were simply given these programmes and they were told to use them), 4. Suggestions to address barriers (they provided suggestions for ways of addressing such barriers, including presence of a mentor, more training in simulation-related issues, carrying out of a rehearsal and creation of backup copies).

In addition, the availability or lack of resources affects the ability of educators to join simulation activities in all courses of study, according to a study by MacKinnon et al ( 50 ).

Some students report that the role of an educator in simulation programmes is very significant and that it must combine the role of a clinical nurse and that of an educator, because this is the only way to enhance learning and the realism of different scenarios ( 51 ).

McAllister et al., ( 52 ) present a series of suggestions for overcoming any barriers and limitations appearing in simulation and maintaining quality in clinical training, while taking practical and pedagogical issues into account. These suggestions include: providing assistance to educators in their work, enabling students to have direct access to clinical skills videos, focusing on teaching clinical skills, utilizing teams in the documentation on skill learning, learning communication skills in an entertaining and imaginative way, and improving time management and prioritization of needs for students.

3.6. The Future of Simulation in Nursing Education

>Nursing science and art constitutes a highly significant and integral part of the health care system. Nurses and their training are fundamental elements of the effectiveness of the system; therefore, special attention is paid and must be paid. Any changes in the training of nurses are interwoven with technological advances, and their training is directly affected by any technological means available for teaching.

The use of simulation as an educational strategy represents a great challenge for nursing education. Simulation may improve health care and patient safety. No patient who is alive is put at risk at the expense of the trainee. Simulation provides standardization of cases, promotes critical thinking, allows supervision of patient care, provides immediate feedback, and helps students to assimilate knowledge and experience. It is an ideal composition learning experience ( 53 ).

Probably the greatest change in nursing education is the introduction of virtual simulation. Continuation and development of virtual simulation constitutes a focal point for nursing science and for the progress of nursing students. This requires investment of funds in the establishment of appropriate laboratories by nursing schools, time for simulation as provided for in the curricula, and educators who are properly trained to create various scenarios and operate simulators. ( 54 )

The use of virtual simulation must become a part of the overall simulation programme. Despite the fact that virtual and augmented reality are at a quite early stage, this option will rapidly spread, as soon as simulation-related technology becomes available and affordable. The quality of simulation devices will provide opportunities for training of students in skills that used to require actual educators in the past, thus opening up new opportunities for schools to reallocate their financial resources.

5. CONCLUSION

The objective of nursing education, apart from the acquisition of solid theoretical knowledge, is the acquisition of clinical skills, which are necessary for graduate nurses to be promptly integrated into the workforce. Integrated learning, critical thinking, and optimal decision-making skills help nurses to provide quality health care. This can be achieved through the inclusion of simulation in the education process. Further development of simulation, along with other educational methods may be of great assistance in the attempt made by students to become integrated and successful healthcare professionals.

Author’s contribution:

All authors were involved in all steps of preparation this article. Final proofreading was made by the first author.

Conflicts of Interest:

There are no conflicts of interest.

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Simulation is frequently used teaching methodology in nursing education and staff development learning environments. Simulation is valued for its ability to provide realistic, context-rich experiential learning in a safe environment. From simulated patients, to low and high fidelity manikins, to virtual reality, each context provides a unique perspective and can facilitate learning and evaluation of patient care situations along the continuum of care. The NLN, in collaboration with Laerdal Medical and Wolters-Kluwer Health, is a recognized leader in simulation development, from unfolding simulations to simulation faculty development courses and virtual simulation scenario development. To promote professional development in this area, the NLN offers a variety of sophisticated resources and activities. ​

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Types of Simulation in Nursing Education

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• Types of Simulation
• Examples of Simulation Scenarios

Preparing for Simulation

• What To Expect
• Pros and Cons of Simulation

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Simulation first appeared in nursing in 1911 when Mrs. Chase, the first mannequin , was used to teach students how to turn, transfer, and dress patients. Simulation techniques have greatly advanced in the last 111 years, but the basic concept remains the same.

Simulation provides a realistic setting and safe environment for students to apply the knowledge they learned in class. Then, they can use what they learned in simulation and apply it to clinical practice.

Simulation might seem like it’s one more complicated thing to add to your already full plate as a nursing student. Consider the pros and cons of simulation, what to expect, and how to complete them successfully.

Nursing students may be familiar with types of simulation in nursing education, such as standardized patients, role playing, and low-fidelity mannequins. Yet, nursing education uses so many more types of simulation.

The online learning environment for nurses brought on by the COVID-19 pandemic forced nursing programs to come up with new ways to teach students nursing skills.

Unfolding Case Studies

Unfolding case studies change over a period of time in a way that the student cannot predict. They help students practice their patient assessment skills. Unfolding case studies allow students to dive deep into their patients’ complex situations, and because some of them are available at no cost, they are cost effective.

Unfolding case studies may also prepare students to apply clinical reasoning and critical thinking skills.

High-fidelity Mannequins

High-fidelity mannequins are computer-controlled full-body mannequins. They most closely replicate the responses, physiology, and anatomy of a patient. Because they are the most adaptable form of simulation, high-fidelity mannequins are typically the most favorable. However, they are also one of the most expensive.

Low-fidelity Mannequins

Low-fidelity mannequins include two-dimensional displays, static models, and partial-task simulators. They are the least real type of simulation. They can help students build knowledge because they allow students to go at their own pace. They can also help students learn a specific skill, such as cardiopulmonary resuscitation or intravenous insertion.

Partial-task Simulators

Partial-task simulators are a body part, such as an arm or a head, that allow nursing students to practice a skill many times without causing wear and tear or using more expensive equipment.

Volunteers Who Act as Standardized Patients

Standardized patients are volunteers who behave in a realistic way to simulate clinical interaction. Standardized patients can make practicing communication and assessment skills more successful. Some of these skills include taking a patient history, asking for informed consent, explaining a procedure, and giving bad news.

Role-Playing

Role-playing asks students to act out a situation. Because role-playing does not require any props or realistic surroundings, this method of simulation is relatively low cost. Despite its low-fidelity, role-playing can benefit students, especially for changing attitudes or team training.

Virtual Reality

Virtual reality uses computers and standardized patients to create a realistic simulation. This form of simulation is still new and gaining popularity in healthcare. Virtual reality can be used to teach patients about complex situations with many people involved because some technologies allow students to care for more than one patient at a time.

E-learning includes all simulations on the computer. These can be a video computer program explaining how to use a device or a highly complicated virtual reality situation where students interact with patients and other healthcare providers.

A Combination of Simulations

A combination of simulations uses two or more of the previous types of simulations to create a more realistic simulation. It can also help students practice more than one skill at a time. For example, an instructor could secure a suture cushion to a standardized patient. In this simulation, the student can practice suturing a wound while getting informed consent and explaining the procedure.

Examples of Simulation Scenarios for Different Classes

The American Nurses Association recommends that the most effective simulations require faculty to coordinate what classes are going to use simulation scenarios. This way, students only repeat key skills in multiple classes. Otherwise, they learn different skills and experience new simulations in each of their classes. Below are examples of common scenarios.

Maternal Health

Students can perform newborn assessments using a newborn simulator or an appropriately sized doll. Students learn how to care for a laboring pregnant individual, especially in high-risk situations such as the pregnant patient hemorrhaging.

Leadership Courses

Students benefit from role-playing scenarios of ethical dilemmas or nurse-to-nurse bullying to learn useful strategies on how to deal with it.

Students can practice infant assessment in a clinical setting. Standardized patients can act as parents or guardians with cultural differences to help students practice with scenarios, such as with a parent or guardian who does not want their child vaccinated.

Mental Health Nursing

Standardized patients help reduce students’ anxiety and stress and build their communication skills by listening to the patients and answering their questions correctly.

Medical-Surgical I or II

Students practice recognizing the signs of stroke in an older patient who was admitted to the hospital for another condition like surgery.

Multiple Classes

Students may practice their skills in patient handoffs, handwashing, and medication safety in multiple classes because those skills need repeating.

Faculty and students must prepare for the simulation, so students can get the most out of the simulation experience. Faculty prepare when they set up the simulation in a way that best helps students meet the objectives of the simulation. Students prepare in the prebriefing stage when they gather information, ask questions, and make a plan of action for the simulation.

Faculty design simulation scenarios that help students best meet the objectives of the simulation and learn the skills they need to be successful. Simulation faculty need to be trained in simulation and debriefing techniques, according to the National Council of State Boards of Nursing Simulation Guidelines and the International Nursing Association of Clinical and Simulation Learning (INACSL) Standards for Designing Simulation .

Other key standards from the INACSL:

• Create a case scenario that provides context for the simulation
• Begin with a prebriefing and end with a debriefing or feedback session
• Provide preparation materials and resources that help students meet the objectives and outcomes of the simulation
• Use an approach based on the participant’s level of knowledge, skills, and experience as well as the outcomes of the simulation
• Structure the simulation to have a starting point that shows the initial circumstances of the patient, structured activities for participant engagement, and an endpoint (that is usually when learning outcomes are achieved)

Students prepare for the simulation in the prebriefing stage. The type of simulation will help determine how students prepare. Some of the ways students can prepare for the simulation include:

• Reviewing key nursing skills like surgical techniques or intravenous insertion
• Preparing a plan of care for the patient and questions for the patient or parent/guardian
• Listening to the prebriefing
• Discussing their approach to the simulation with their classmates
• Researching the patient’s condition

What to Expect in Nursing Simulation

Well-planned, effective simulation consists of three phases: prebriefing, simulation, and debriefing. Faculty must plan for and students must participate in all three phases for the simulation to be successful.

Pros and Cons of Simulation in Nursing Education

Simulations provide students with a safe environment to practice skills as much as needed without harming patients. However, they can be costly, they cannot replicate the clinical situation, and they can cause students to learn incorrect information if designed poorly.

• Aebersold M. (2018). Simulation-based learning: No longer a novelty in undergraduate education.
• https://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-23-2018/No2-May-2018/Articles-Previous-Topics/Simulation-Based-Learning-Undergraduate-Education.html
• At 101, ‘Mrs. Chase’ is a medical marvel. (2012). https://www.courant.com/
• Fogg N. (2020). Transitioning from direct care to virtual clinical experiences during the COVID-19 pandemic. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7540562/
• Galloway S. (2009). Simulation techniques to bridge the gap between novice and competent healthcare professionals. https://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol142009/No2May09/Simulation-Techniques.html
• Hargreaves L, et al. (2021). COVID-19 pandemic impact on nursing student education: Telenursing with virtual clinical experiences. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8529906/
• INACSL standards of best practice: SimulationSM simulation design. https://www.nursingsimulation.org/action/showPdf?pii=S1876-1399%2816%2930126-8
• Increasing fidelity and realism in simulation for nursing students . (2018). https://www.wolterskluwer.com/en/expert-insights/increasing-fidelity-and-realism-in-simulation
• Koukourikos K, et al. (2021). Simulation in clinical nursing education. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8116070/pdf/AIM-29-15.pdf
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• Unfolding cases. (2020). https://www.nln.org/education/teaching-resources/professional-development-programsteaching-resourcesace-all/ace-s/unfolding-cases

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1 Curriculum Integration of Simulations

Learning Objectives

Upon completion of this learning module, the learner will:

• Discuss the elements of systematic/purposeful integration of simulations in curriculum
• Analyze enhancers/barriers to successful integration of simulations in curriculum
• Create a plan for systematic integration of simulations in nursing curriculum

Introduction:

                  Simulation is an integral component of nursing education because it allows for a safe, timely, and prescriptive approach to meet learning objectives at the levels of simulations, courses and academic programs (Franklin & Blodgett, 2021). There is currently an extensive amount of literature supporting the ability of simulations to provide rich learning experiences, especially clinical situations that they might not have had access to as students/learners.  However, isolated simulation encounters that are not carefully integrated into an organized curriculum can result in ineffective and inefficient use of time for both educators and learners (Franklin & Blodgett, 2021; Herrington & Schneiderith, 2017; Howard et al, 2019; Thomas et al, 2016).  It is, therefore, imperative that nurse educators and simulationists exert efforts to ensure the systematic integration of simulations in curricula in academic, and even in practice settings. Simulation-based education is a costly educational modality, and the maximum benefits can be achieved, when simulations are well integrated in the curriculum to meet not just individual simulation objectives, but course and program objectives as well (Masters, 2014). Like any novel undertaking in educational programs, a curricular integration framework must be used, and a curricular plan made available for implementation and evaluation. This learning module unfolds to discuss the concept of curricular integration, theoretical and empirical bases for simulation-based education in nursing curriculum, and essential steps and elements of curricular integration. Exercises to check knowledge and apply learned concepts are included along with video resources to further highlight concepts of curricular simulation integration.

Knowledge Check:

I.   Integration of Simulations in Nursing Curricula

           Curriculum simulation integration, among other definitions, is the coordinated and purposeful use of simulation-based learning methods to meet predetermined learning goals within an approved curriculum (Franklin & Blodgett, 2021). Simulations are incorporated in each course or level to promote psychomotor, cognitive and affective domains of learning (Schram & Aschenbenner, 2014). Simulations are used in different settings in nursing education; from simulated clinical situations to replace part (or all) of clinical experiences that traditionally happen in real patient care situations, to simulations used to illustrate clinical experiences in the classroom. The National League of Nursing (NLN) Vision Series (National League for Nursing, 2015) articulates the vision of using simulations across the curriculum: simulation pedagogy transcending the simulation laboratory and viewed as an innovative way, a break from the long held nursing education traditions.

Curriculum and Simulation: Are they related?

II:   Theoretical and Empirical Support for Simulation-Based Education in Nursing

Empirical Bases

Aul et al. (2021) found systematic curricular integration of simulations in a nursing program curriculum enhanced teaching and learning needs of faculty. The authors research is not an isolated study. The National Council of State Boards of Nursing (NCSBN) National Simulation Study generated support of simulations replacing 25%-50% of traditional clinical experiences (Hayden et al, 2014). Unlike traditional clinical education, empirical support of the use of simulations in clinical education has advanced and has been used to support standards of best healthcare simulations (INACSL, 201) and guidelines for using simulations in nursing education (NCSBN, 2016). The NLN (2015) advocates for debriefing across the curriculum; and NCSBN (2016) Simulation Guidelines for prelicensure nursing programs cite several systematic reviews and the National Simulation Study to support the use of simulations in nursing curriculum:

• Lapkin et al. (2010) conducted a systematic review of eight studies that met their inclusion criteria. They found that simulation improved critical thinking, performance of skills, knowledge of the subject matter and an increase in clinical reasoning in certain areas . Two integrative reviews of undergraduate nursing’s use of simulation focused on patient safety.
• Berndt (2014) reviewed seventeen studies, including 3 systematic reviews. Their findings support the use of simulation as an educational intervention to teach patient safety in nursing, particularly when other clinical experiences aren’t available .
• Fisher & King (2013) conducted an integrative review related to patient safety in that they examined 18 studies preparing students, through simulation, to respond to deteriorating patients. They found that, in general, confidence, clinical judgment, knowledge and competence increased through the use of simulation. 
• The largest and most comprehensive study to date examining student outcomes when simulation was substituted for up to and including 50% simulation was NCSBN’s National Simulation Study (Hayden et al., 2014). This longitudinal, randomized, controlled study replaced clinical hours with simulation in prelicensure nursing education. In ten nursing programs from across the country (five BSN and five ADN), students were followed through all clinical courses in their nursing programs as well as through their first six months of practice. The study provided evidence that when substituting clinical experiences with up to 50% simulation, there were no statistically significant differences between the groups using 10% or less of simulation (control), 25% simulation or 50% simulation with regard to knowledge acquisition and clinical performance. In conclusion, the literature provides evidence that simulation is a pedagogy that may be integrated across the prelicensure curriculum, provided that faculty are adequately trained, committed and in sufficient numbers; when there is a dedicated simulation lab which has appropriate resources; when the vignettes are realistically and appropriately designed; and when debriefing is based on a theoretical model. 

Simulation research has advanced to what it is today, establishing its relevance and necessity in nursing education. It is important for nurse educators, as they attempt to integrate simulations in the nursing curriculum to be cognizant of current empirical evidences and guidelines for using simulations in nursing education.

Theoretical Bases

The theoretical bases of simulation are sound learning theories, and are frequently used in simulation education and research:

• Kolb’s Experiential Learning Theory:

Kolb describes a cognitive learning process where individuals have concrete experiences, followed by reflection, generation of abstract conceptualizations and application of new knowledge to future practice (Franklin & Blodgett, 2020, citing Kolb, 1984) (See image above). Kolb’s theory resonates with modern nursing simulation: active participation in a simulation experience (concrete experience), followed by reflective observation and abstract conceptualization occur in debriefing of simulations. The cycle is completed through learners active experimentation of learned practice in another simulation or in actual patient care.

Reflection Question

How can nurse educators use Kolb’s Experiential Learning Theory in planning for real and simulated students’ clinical learning experiences?

2. Cognitive Load Theory

Cognitive Load Theory in a nutshell:

The application of Cognitive Load Theory is  discussed in the following video.  Cognitive load theory underpins simulation scenario design.

Key Takeaways

As nurse educators, how do we take into account intrinsic load, germane load and extraneous load of our learners in the design and facilitation of simulations? What are the implications in curricular integration?

• What are your prebriefing plans?
• How simple or complex are the simulations in each course? Are they appropriate for the learner’s level in the program?
• Reflect on other ways to use this frame (Cognitive Load Theory) in your curriculum.

3. NLN Jeffries Simulation Theory

The following are notable points of the theory based on NLN Jeffries Simulation Theory: Brief Narrative Description (Jeffries et al., 2015).

• Context refers to contextual factors that need to be taken into consideration when designing and evaluating simulations such as setting and overarching purpose of simulation.
• Background refers to the theoretical perspective for the specific simulation experience and how the simulation fits into the larger curriculum.
• Design includes specific learning objectives that guide the development or selection of activities and scenarios with appropriate content and problem-solving complexity (physical and conceptual fidelity, roles, scenario progression, and prebriefing and debriefing strategies)
• Simulation Experience is characterized by an environment that is experiential, collaborative and learner-centered (psychological safety, suspension of disbelief)
• Facilitator and Educational Strategies in the context of the simulation experience is a dynamic interaction between facilitator and participant. Some of the important facilitator attributes include skill, educational techniques and preparation. For example: “The facilitator responds to emerging participant needs during the simulation experience by adjusting educational strategies such as altering the planned progression and timing of activities and providing appropriate feedback in the form of cues (during) and debriefing (toward the end) of the simulation experience.”
• Participant innate attributes include age, gender, level of anxiety and self-confidence, whereas preparedness for simulation is modifiable.
• Outcomes: a) Participant outcomes include reaction, learning, behavior;  b) Patient and c) System

In planning for Curriculum Integration:

• Our plans to integrate simulations in existing simulation must be based in sound educational theories
• The planning, design, implementation and evaluation of simulations must be planned in curricular integration using the NLN/Jeffries Simulation Theory.

III. Curriculum Integration Framework

This video provides an outline of curriculum integration and important concepts will be highlighted in the text below (GWU School of Nursing open educational resource):

A. Needs Assessment

(Kern’s Steps 1 and 2)

Understanding the following required elements is necessary to determine the need to integrate simulations in the curriculum:

• Underlying cause of concern
• Organizational analysis
• Stakeholders’ survey
• Program outcome data
• Self-study comparing current practices to INACSL standards of healthcare simulations
• Accreditation reports
• Standardized test results
• Didactic Examinations
• Feedback from clinical partners
• QSEN competencies
• Learners Needs and learning style preferences

Highlighting the need for Inter-professional Education (IPE) and Simulation Enhanced IPE (SIM-IPE)

A statement indicating the desired state, compared to current state, supported by objective data and standards of best practice, is needed to propose a curricular integration of simulations in the curriculum.

B. Goals and Objectives-  Curricular mapping

(Kern’s step 3)

The learning goals and objectives of simulations must be linked to content, courses, and the overarching program outcomes. A curricular map will allow faculty to scaffold simulation experiences and build and content and complexity from previous courses. Scaffolding allows learners to demonstrate knowledge, skills and attitudes, add new knowledge, and apply new material. Scaffolding promotes learning efficiency (Franklin & Blodgett, 2020). Curricular mapping requires input from faculty across the curriculum along with simulation faculty. Simulations objectives must be specific, measurable, achievable, realistic, and time bound (SMART), and must be linked to unit objectives, course objectives and end of program student learning outcomes.

• Determine how content can be thoughtfully linked to context
• Lay out a curricular map to explore areas needing improvement
• Match simulation to didactic content for each course

Curricular alignment is a linear configuration between program outcomes, course outcomes, and simulation outcomes. If program outcomes drive course outcomes, then course outcomes should drive simulation outcomes. If we design simulations that adhere to the Standards, then all  simulations should clearly map back to program outcomes. Simulations are no longer run to compensate for clinical time or replace hours lost to other activities, but instead are designed to address specific course outcomes (Schneidereith & Beroz, 2017).

This is an example of a Curriculum Map Worksheet:  MCSRC Simulation Curriculum Map Worksheet

C. Educational Strategies

(Kern’s Step 4)

• Simulation is an educational strategy that is framed by educational theories, including constructivism, experiential learning, and andragogy. Current standards of healthcare simulations provide guidance to educators on design, implementation, and evaluation of this teaching-learning modality. See HEALTHCARE SIMULATION STANDARDS OF BEST PRACTICE™
• Planning and Sequencing Simulation Experiences: Thoughtful curricular integration reduces the variability brought about by different clinical experiences; nurse educators will need to plan to include simulations that allow students to safely practice frequently required competencies along with the ability to practice clinical situations that students are not otherwise able to practice independently because of safety and legal considerations. Nurse Educators will need to plan and make decisions on writing simulation scenarios or utilize peer reviewed scenarios. Both will require alignment with course and program learning objectives.
• Simulations are a powerful teaching and learning modality beyond the simulation laboratory. An example is illustrated in the resources below:

D. Implementation

( Kern’s Step 5)

• The simulation experience should have maximum realism so that students do not spend cognitive energy understanding what is real and what must be imagined (Franklin & Blodgett, 2020; Screws & Cason, 2019). This has huge implications on budgeting operations; faculty must present a strong business case on the maximum return or gains in the integration of simulations in the curriculum.
• Utilizing Simulation Education Resources: Although simulations can curricular needs and gaps, available and potential resources must be taken into consideration such as: faculty and administrative support, size of student population/cohorts, clinical hours, clinical to simulation hours ratio, faculty competencies, simulation space and set up, and debriefing space.
• It is crucial to match the level of fidelity and the level of learners’ level of experience; it is important that the level of fidelity matches both scenario objectives and learners’ needs.  Simulation modalities and their availability are important factors to consider in the implementation of simulations. Various modalities include low to high fidelity manikins, standardized patients (actors), tasks trainers, virtual simulation modalities, visual aids and computer systems and competent staff. These are elements that will enhance implementation of simulation-based curriculum.

Highlight on Standards of Best Practice in Simulations and Standardized Patients/Human Players

The Association of Standardized Patient Educators (ASPE) Standards of Best Practice (SOBP)

Podcast: Learning From Our Failures: SPs from Center for Medical Simulation

Reflection: What special considerations do we consider as nurse educators in using Standardized Patients in the Curriculum?

VIRTUAL SIMULATION

Tolarba (2021) states virtual simulation (VS) is more effective than simulation in a nursing lab; VS improves affective and cognitive domains of learning, increases students’ clinical skills, technology skills, confidence, and enjoyment.

What is VS and how can it be integrated into curriculum? How can you evaluate it’s effectiveness? Click here to find out: Virtual Simulations SEL II_2023.pptx

This is a comprehensive educator’s toolkit on the use of virtual simulations in healthcare

F. Evaluation of Simulations

(Kern’s Step 6)

• 1. total number of anticipated simulations
• 2. student learning
• 3. students’ simulation experience (whether or not the experience is being implemented consistently across classes and courses, for example)
• 4. the simulation program as a whole (how effective it is at positively impacting outcomes, for example)
• 5. faculty development including roles and responsibilities and best practices in using simulation
• 6. evaluation of faculty facilitation (how does it compare to the facilitation conducted in the classroom?) (Tagliareni & Forneris, 2017).
• Evaluation results data for each individual simulation encounter should be analyzed and incorporated back into the course. Analysis should address whether the activity met the learning outcome for the course, using quantitative data (which many of the instruments referenced above are designed to measure) so that faculty can quantify learning and thus, more easily map the data to student, course, and curriculum outcomes (Tagliareni & Forneris, 2016).
• The NLN/Jeffries Simulation Theory frames the needs and elements of evaluation of simulations (Jeffries, et al., 2016).  A repository of instruments is found in INACSL Repository of Instruments used in Simulation Research   and the standards are written in  Healthcare Simulation Standards of Best PracticeTM Evaluation of Learning and Performance

Question: What lessons can we take from the article that will lead our programs to successful integration of simulations?

V. Dr. Pamela Jeffries puts all the concepts to consider in curriculum integration all together in this talk to SESAM

VI   Additional Resources:

• NCSBN Simulation Guidelines for Prelicensure Nursing Programs

2.  MCSRC Summer 2020 Speaker Series: Curricular Integration by Tonya Scheneiderith

3.  Video Series: Debriefing in the Classroom and beyond:

• Debriefing in the classroom

2. Debriefing Post-Clinical Day:

3. Debriefing a critical incident in clinicals:

References:

Aul, K., Bagnall, L., Bumbach, M. D., Gannon, J., Shipman, S., McDaniel, A., & Keenan, G. (2021). A key to transforming a nursing curriculum: Integrating a continuous improvement simulation expansion strategy. SAGE Open Nursing ,  7 , 2377960821998524.                                                     https://doi.org/10.1177/2377960821998524

Franklin, A. E., & Blodgett, N. P. (2020). Simulation in undergraduate education. Annual Review of Nursing Research ,  39 (1), 3–31. https://doi.org/10.1891/0739-6686.39.3

Jeffries, P. R., Rodgers, B., & Adamson, K. (2015). NLN Jeffries simulation theory: Brief narrative description. Nursing Education Perspectives ,  36 (5), 292–293. https://doi.org/10.5480/1536-5026-36.5.292

Masters K. (2014). Journey toward integration of simulation in a baccalaureate nursing curriculum.  The Journal of Nursing Education ,  53 (2), 102–104. https://doi.org/10.3928/01484834-20131209-03.

National League for Nursing (2015). NLN vision series: A vision for teaching with simulation . https://www.nln.org/docs/default-source/uploadedfiles/about/nln-vision-series-position-statements/vision-statement-a-vision-for-teaching-with-simulation.pdf?sfvrsn=e847da0d_0

Tagliareni, E & Forneris, Susan (2016). Curriculum and simulation: Are they related? Wolters Kluwer/National League for Nursing. White Paper.

The Nurse Educators' Guide to Simulation-Based Education Copyright © 2022 by Raquel Bertiz and Jasline Moreno is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License , except where otherwise noted.

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Nln center for innovation in education excellence, simulation: how do we best prepare and train our educators where do we begin.

• by NLN Nursing EDge
• Posted on January 28, 2022

By: Beth Hallmark, PhD, RN, MSN, CHSE-A, ANEF; Sabrina Beroz, DNP, RN, CHSE-A, FAAN; and Penni Watts, PhD, RN, CHSE-A

This past year, as the  pandemic swept the world creating challenges for educators and learners, simulation has been brought to the forefront of nursing education. This leads us to ask: How do we best prepare and train our faculty/simulation educators? Where do we begin?

It certainly is a hot topic, as demonstrated by the number of questions and comments on list servs and other forums. There are so many questions on how to get started, what to include in your training, and how much training is enough.

Well, you are in luck! The new and improved Healthcare Simulation Standards of Best Practice™ were published in fall 2021. Included in this publication is a new standard entitled Healthcare Simulation Standards of Best Practice™ Professional Development that provides a simple guide to direct simulationists in their professional journey. 

Professional development is not a one-time shot – it is ongoing. The role of a simulationist and the elements of each job description vary from institution to institution. The Professional Development standard ensures “the simulationist is trained at all levels of simulation design, implementation, and evaluation” (INACSL Standards Committee and Hallmark et al., 2021, p.5). We have a few suggested steps to get you started!

• Work with your faculty and other educators by doing a needs assessment. Have them do a self-assessment. What knowledge do they bring? What strengths do they have? What is their role in simulation? Use this information to create a development plan. We all come with different backgrounds and experiences so how to get started is not always clear cut – one size does not fit all.
• The 2021 edition of the Annual Review of Nursing Research focused on simulation-based education. Watts, Hallmark, and Beroz (2021) contributed a chapter on professional development for simulation education and offer a framework for providing simulation content based on Benner’s novice to expert theory as in the table below.
• Be sure to look at the evidence for developing your faculty/educators. The new standard provides a multitude of resources.
• Attend a simulation conference, participate in a webinar, network with other simulationists, or even complete a certificate program.
• Look for local and regional alliances such as the Tennessee Simulation Alliance or the California Simulation Alliance .
• The NLN has several sources such as the Simulation Innovation Resource Center (SIRC) , as well as free webinars .
• Join professional organizations such as the Society for Simulation in Healthcare , INACSL , ASPE , and the Global Network for Simulation in Healthcare .

There are always challenges. The most common are lack of time and the availability of resources. Sound familiar? Educators fill many roles with competing demands. However, the pandemic has shown simulation to be a profound methodology to meet expected teaching-learning outcomes.

The benefits of trained educators are abundant. According to the Healthcare Simulation Standard of Best Practice TM Facilitation, having trained educators is imperative for quality simulation experiences and positive outcomes. REMEMBER: The facilitator has full oversight for the simulation experience.

And one final step. Be sure to reevaluate your professional development progress and update your plan!

INACSL Standards Committee, Hallmark, B., Brown, M., Peterson, D., Fey, M., Decker, iS., Wells-Beede, E., Britt, T., Hardie, L., Shum, C., Arantes, H., Charnetski, M., & Morse, C.  (2021). Healthcare Simulation Standards of Best Practice TM Professional Development. Clinical Simulation in Nursing. https://doi.org/10.1016/j.ecns.2021.08.007

INACSL Standards Committee, Persico, L., Belle, A., DiGregorio, H., Wilson-Keates, B., & Shelton, C.  (2021). Healthcare Simulation Standards of Best Practice TM Facilitation. Clinical Simulation in Nursing, https://doi.org/10.1016/j.ecns.2021.08.010

Watts, P.I., Hallmark, B.F., & Beroz, S. (2020). Professional Development for Simulation Education. In C. Kasper & T. Schneidereith (Eds), Annual Review of Nursing Research , 39 (1), 201-220. https://pubmed.ncbi.nlm.nih.gov/33431643/

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• Open access
• Published: 22 February 2022

Integrating simulation training during clinical practice in nursing homes: an experimental study of nursing students’ knowledge acquisition, self-efficacy and learning needs

• Camilla Olaussen 1 , 2 ,
• Simen A. Steindal 1 ,
• Lars-Petter Jelsness-Jørgensen 1 , 3 , 4 ,
• Ingunn Aase 5 ,
• Hege Vistven Stenseth 1 &
• Christine Raaen Tvedt 1  

BMC Nursing volume  21 , Article number:  47 ( 2022 ) Cite this article

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Limited access to supervision, feedback and quality learning experiences pose challenges to learning in the clinical setting for first-year nursing students who are beginning their clinical experiences. Prior studies have indicated that simulation training, as a partial replacement of clinical practice hours, may improve learning. However, there has been little research on simulation training integrated as a partial replacement during first-year students’ clinical practice in nursing homes. The primary aim of this study was to examine first-year nursing students’ knowledge acquisition and self-efficacy in integrating a partial replacement of clinical hours in nursing homes with simulation training. Its secondary aim was to examine perceptions of how learning needs were met in the simulated environment compared with the clinical environment.

The primary aim was addressed using an experimental design that included pre- and post-tests. The secondary aim was investigated using a descriptive survey-based comparison.

First-year students at a Norwegian university college ( n  = 116) were asked to participate. Those who agreed ( n  = 103) were randomly assigned to the intervention group ( n  = 52) or the control group ( n  = 51). A knowledge test, the General Self-efficacy Scale and the Clinical Learning Environment Comparison Survey were used to measure students’ outcomes and perceptions. The data were analysed using independent samples t -tests, chi-square tests and paired samples t -tests.

Knowledge scores from pre- to post-tests were significantly higher in the intervention group than in the control group with a medium to large effect size ( p <  0.01 , Hedges’ g =  0.6). No significant differences in self-efficacy were identified. Significant differences ( p  <  0.05) were observed between the simulated and the clinical environment with regard to meeting learning needs; effect sizes ranged from small and medium to large (Cohen’s d from 0.3 to 1.0).

Integrating the partial replacement of clinical hours in nursing homes with simulation training for first-year nursing students was positively associated with knowledge acquisition and meeting learning needs. These findings are promising with regard to simulation as a viable partial replacement for traditional clinical practice in nursing homes to improve learning.

Peer Review reports

The Norwegian Coordination Reform, which was introduced in January 2012 [ 1 ], has resulted in the transferral of patients suffering serious, complex and treatment-intensive conditions to nursing homes, thus placing extensive demands on staffing and competence [ 2 ]. In addition, nursing homes often struggle with nurse shortages due to recruitment difficulties and high turnover [ 3 , 4 ]. Nursing education programmes are essential in meeting increasingly complex care needs and demands, recruiting and retaining nurses in bedside positions and ensuring future patient safety and quality in nursing homes [ 5 ].

Supervised experiences with patients in real clinical settings are an important part of nursing students’ clinical education [ 6 , 7 ]. According to the traditional Norwegian clinical education model for first-year nursing students, all hours of clinical practice are conducted in nursing homes and supervised by onsite registered nurses [ 8 ]. Nursing students need feedback, guidance and support to acquire the knowledge of managing challenging learning situations in clinical practice and to build competency for self-efficacy and safe patient care [ 9 , 10 ]. However, students’ access to supervision, feedback and quality learning experiences is not always optimal [ 11 , 12 ]. In nursing homes, the limited number of registered nurses that serve as supervisors can pose a significant challenge to the learning of first-year students who are just beginning their clinical experiences [ 13 , 14 , 15 ]. Prior studies have indicated that integrating simulation training as a partial replacement of clinical practice hours may improve learning [ 16 , 17 ].

When used as preparation for clinical practice, studies have reported that simulation training has positive effects on student outcomes such as knowledge, decision-making, self-confidence and self-efficacy [ 18 , 19 , 20 ]. In an umbrella systematic review, Cant and Cooper [ 19 ] found that simulation training statistically improved self-efficacy in pre- and post-test studies, and in experimental designs self-efficacy was superior to that of other teaching methods. Further they found that many reviews agreed on outcomes of knowledge, although no overall quantitative effect was derived [ 19 ]. In a randomized controlled trial comparing students’ knowledge and self-confidence scores before and after attending simulation training, Haddeland et al. [ 20 ] identified significantly greater improvement in the intervention group compared with the control group. A systematic review and meta-analysis on the effectiveness of simulation training based on life-threatening clinical condition scenarios found no significant effect on students’ self-confidence and self-efficacy but demonstrated that simulation training is superior to other teaching methods in improving knowledge and performance [ 21 ]. However, there are few previous studies on the partial replacement of clinical hours by simulation training among first-year students in nursing homes. The National Council of State Board Nursing’s (NCSBN) National Simulation Study was a two-year longitudinal, randomised controlled study in which clinical hours were replaced by 25 and 50% simulation training in two intervention groups, respectively. These intervention groups were then compared with a control group that had up to a 10% replacement. No statistically significant differences between the groups were found [ 22 ]. However, the NCSBN study showed a possible advantage of partial replacement for the development of clinical competency in the medical-surgical and community health areas, but a potential disadvantage in the perinatal, paediatric, and mental health areas [ 22 , 23 ]. Curl et al. [ 24 ] used a quasi-experimental design and found that students who replaced 50% of clinical practice in obstetrics, paediatrics and mental health had similar or better results with regard to knowledge than those who had undergone traditional clinical practice. A systematic review found that replacing clinical hours by simulation training had no significant impact on student outcomes, such as knowledge acquisition and self-confidence, compared with traditional clinical practice [ 23 ]. A meta-narrative review by Roberts et al. [ 25 ] found no significant differences in student outcomes but highlighted that the lack of clearly stated number of hours of simulation versus number of clinical hours meant the generalisability of research findings was difficult.

Roberts et al. [ 25 ] reported the need for continued research to determine the possible advantages or disadvantages of simulation training as a partial replacement for clinical hours. Davis et al. [ 26 ] emphasised that it is essential to determine the optimal combination of simulation and clinical hours. Larue et al. [ 23 ] called for studies to examine various simulation–clinical combinations, depending on the clinical context to which students are exposed. Simulation training as a partial replacement during clinical practice in nursing homes for first-year students is a combination of simulation and clinical training that has not yet been well studied.

In the current study, we examined knowledge acquisition and self-efficacy among first-year nursing students who received a 10.7% partial replacement of clinical hours in nursing homes with simulation training (the intervention group) and first-year nursing students who received the traditional Norwegian education model with clinical studies limited to nursing homes (the control group). As a secondary aim, we examined how well learning needs were met in the clinical environment compared with the simulated environment among the students in the intervention group.

The primary aim was addressed using an experimental design that included pre- and post-test comparisons of students’ knowledge and self-efficacy in the intervention group (the combination of simulation–clinical training) versus the control group (only clinical training). The secondary aim was addressed using a descriptive survey-based comparison in the intervention group.

Participants and setting

The study was conducted at a Norwegian university college that provides nursing education at the bachelor level. One class of first-year nursing students ( N  = 116) who were enrolled in the second semester of their bachelor education during the spring of 2020 were asked to participate. Those who agreed ( n  = 103) were randomly assigned to either the intervention group ( n  = 52) or the control group ( n  = 51). Randomisation was performed by the university administration staff using the random between function in Microsoft Excel to avoid selection bias. Three students from the control group left the education programme before the initial pre-test, which resulted in a control group of 48 students and a total of 100 participants. Before the practice placement period commenced, the university administration staff ensured that the students in the intervention group were placed in nursing homes that were different from those assigned to the control group. None of the 13 nursing homes involved offered simulation training for students during the practice period.

The control group: “traditional clinical practice”

The control group attended a seven-week practice period of 224 h in nursing homes, which is hereafter referred to as “traditional clinical practice” .

The intervention group: “clinical practice with simulation as partial replacement”

The intervention group attended a seven-week practice period of 224 h in nursing homes, of which 24 h (10.7%) were replaced by simulation training on three separate days during the practice period, which is hereafter referred to as “clinical practice with simulation as partial replacement”.

Description of the intervention: clinical practice with simulation as partial replacement

The simulation training was scheduled in weeks 2, 4 and 6 of the seven-week practice period. The INACSL Standards of Best Practice: Simulation© and the National League for Nursing/Jeffries simulation theory, which provide systematic steps for designing quality simulation experiences, guided the design of the simulation training [ 27 , 28 ]. The scenarios used in the simulation training were designed to resemble situations that students were likely to encounter in their nursing home practice. To enhance the level of fidelity in the scenarios, high technology full-body mannequins (NursingAnne®; Laerdal™) with vital signs that reflected the patient’s diagnosis were used, the patient’s environment was designed to replicate a nursing home, and the students could immerse themselves in the simulation experiences as autonomous clinicians making their own decisions and demonstrating their knowledge [ 27 , 29 , 30 ]. The patient scenarios are presented in Table  1 .

Previous research has suggested a 2:1 clinical-to-simulation ratio (i.e., two clinical hours count as 1 h of simulation training) because of the intensity and efficiency of simulation training compared with the clinical setting [ 11 , 16 , 24 ]. Because of the resources available in this study, the university administration gave permission to replace 3 days (24 h, 10.7%) of the 28 days (224 h) in “traditional clinical practice”. Each day was replaced by the following: i) time for students to prepare for the simulation training individually by reading preparation materials before the simulation training commenced (1 h); ii) the simulation training which included three steps: initial briefing, the active simulation, and debriefing (3 h with a 2:1 simulation ratio = 6 h); and iii) time for the students to write individual reflection notes after the simulation training was completed (1 h). Preparation materials with information about logistics, meeting times, specific scenarios, and learning objectives were provided before each simulation training and were accessible by students in their learning management systems.

The intervention group attended the simulation training in six groups of eight to ten students each. Each simulation training started in step 1, the initial briefing (30–45 min), that offered an overview of the environment, objectives and technical equipment [ 31 ]. In step 2, three to four students participated as nurses in active simulations (30–40 min), while the other students held the role of active observers. The students switched roles during the simulation training days, which allowed all students to practice as nurses. In step 3, the scenarios were deconstructed and analysed in a facilitated debriefing that lasted a minimum of 90 min. The Promoting Excellence and Reflective Learning in Simulation (PEARLS) framework was used to guide the debriefing in four distinctive phases: the reaction, the description, the analysis and the summary phase [ 32 ]. Two experienced facilitators employed at the university college (i.e., the fifth author and an additional teacher) conducted the briefing, the active simulation and the debriefing, while the simulation operators regulated the technical features of the simulator and presented the patients’ voices.

Data collection

To achieve the primary aim, data were collected using a multiple-choice knowledge test and the General Self-efficacy Scale (GSE). The Clinical Learning Environment Comparison Survey (CLECS) was used to achieve the secondary aim. The participants completed all questionnaires electronically.

Data collection: primary aim

The data collected at different time points related to the primary aim are presented in Table  2 . Pre- and post-tests were completed 1 week prior to and 1 week following the clinical practice, respectively.

Knowledge test

The knowledge test was specifically designed for the present study, as no appropriate tests were identified in the literature. The multiple-choice test contained 30 questions on the areas of respiration, circulation, elimination and drug handling. The test was developed based on the students’ curriculum and expected learning outcomes during clinical practice in the nursing homes. Four response alternatives in addition to “I don’t know” were given. Only correct answers were given one point, and higher scores were indicative of better learning outcomes (scores ranged from 0 to 30 points). The facilitators in the simulation training were blinded to the content of the knowledge test to reduce method bias that could affect the intervention group’s test outcomes.

A panel of experts comprising four teachers responsible for first-year education courses was consulted to ensure the content validity of the test [ 33 ]. In addition, the test was administrated to four second-year nursing students who were asked to evaluate the structure, meaning of the questions, wording and test instructions [ 34 ]. The last step was to pilot the final test version in a group of 15 s-year nursing students to detect potential flaws and weaknesses and to estimate a provisional standard deviation (SD) for the power analysis.

The GSE (Norwegian version)

The GSE is a 10-item psychometric scale that is designed to assess optimistic self-beliefs to cope with difficult demands. The scale has been translated into Norwegian and validated [ 35 ]. The GSE uses a four-point scale that measures the respondents’ agreement with the statements (1 = Not at all true, 2 = Hardly true, 3 = Moderately true, 4 = Exactly true), with a score from 10 to 40 points. A high score represents a more optimistic assessment of general self-efficacy.

Data collection: secondary aim

Clecs (norwegian version).

The CLECS was administered to the intervention group to examine the students’ perceptions of how well learning needs were met in the simulated versus the clinical environment 1 week following the clinical practice period. The CLECS is specifically designed for this purpose, and it has been psychometrically tested in Norwegian [ 36 , 37 ]. Items are scored using a four-point Likert scale: 1 = “Not met”, 2 = “Partially met”, 3 = “Met”, 4 = “Well met”, in addition to “not applicable”. For each item, the students selected a score for both the clinical and the simulated environment [ 37 ]. The results were provided as mean scores for the clinical environment and for the simulated environment in six subscales: Communication (four items); Nursing Process (six items); Holism (six items); Critical Thinking (two items); Self-Efficacy (four items); and the Teaching–Learning Dyad (five items).

The variables used to address the primary aim of the study were the pre- and post-knowledge and self-efficacy mean scores from both groups. The variables used to address the secondary aim of the study were the intervention group’s mean scores on the six subscales in the CLECS for both the clinical environment and the simulated environment.

Data analyses

A power analysis with a provisional SD of 3.9 estimated from the pilot testing of the knowledge test showed that a sample size of 27 students in each group was sufficient to identify a difference in improvement of 3 points, with a maximum risk of a type 1 error of 5% ( p  <  0.05) and a strength of 80%. Descriptive statistics are presented as means and SD for continuous variables and as frequencies and proportions for the categorical variables. Differences in demographic variables, self-efficacy and knowledge scores between the groups were analysed using independent sample t -tests (two-tailed) and chi-square tests. Differences in self-efficacy and knowledge scores within the groups and differences in how well learning needs were met in the clinical environment compared with the simulated environment were detected by paired sample t -tests (two-tailed). Hedges’ g was used to calculate the effect sizes for the independent sample t -tests (by dividing the mean difference between the groups by the pooled SD with weights for the sample sizes). Cohen’s d was used for the paired sample t -tests (by dividing mean differences by the SD of the difference). Cohen’s [ 38 ] operational definitions of small (= 0.2), medium (= 0.5) and large effects (= 0.8) were used.

The significance level was set at 5%, p  <  0.05. IBM SPSS Statistics version 26 (IBM, Armonk, NY, USA) was used to conduct the analyses.

Ethical considerations

The study was approved by the Norwegian Social Science Data Services (ref. 875,320) and performed in accordance with the 2013 revised version of the Declaration of Helsinki. Participation was voluntary and based on written informed consent. It had no consequences for the students’ educational progression. Students could withdraw at any point during the study.

None of the study participants had prior experience in simulation training. The pre-test was completed by 97 of 100 (97%) students, of whom 52 were assigned to the intervention group (53.6%) and 45 were assigned to the control group (46.3%). There were no significant differences in demographic variables, baseline knowledge or self-efficacy scores between the groups (data not shown). The post-test was completed by 88 of these 97 students (90.7%), whereas 50 students were in the intervention group (57%) and 38 students were in the control group (43%). There were no statistically significant differences in the demographic variables, baseline knowledge or self-efficacy scores between the control group ( n  = 38) and the intervention group ( n  = 50) for those who completed both the pre- and post-tests (Table  3 ).

The dropout rate for the control group was 20.8, and 3.8% for the intervention group.

Knowledge and self-efficacy

Differences in knowledge scores from pre- to post-test within the control group and the intervention group were statistically significant, while differences in self-efficacy scores from pre- to post-test within the groups were not (Table  4 ). There were statistically significant differences in the post-test knowledge scores between the intervention group and the control group (mean difference 3.6, 95% Cl 2.1–5.0, p  < 0.01, Hedges’ g = 0.9) . However, no statistically significant differences in post-test self-efficacy scores were observed between the groups (mean difference 1.4, 95% Cl − 0.9 – 3.0, p  = 0.1, Hedges’ g = 0.1).

The mean improvement in knowledge scores from the pre-test to the post-test was higher in the intervention group than in the control group (Table 4 ). The difference in mean improvement between the groups was statistically significant (mean difference 2.2, 95% Cl 0.6–3.8) with a medium to large effect size (Table 4 ). No statistically significant difference in mean self-efficacy improvement between the pre-test and the post-test were observed in the control versus the intervention group (mean difference 0.5, 95% Cl − 1.2 – 2.1) . A small effect size was also observed (Table 4 ).

Perceptions of how learning needs were met in the intervention group

Mean scores in the intervention group on how learning needs were met were significantly higher in the simulated learning environment than in the clinical environment on all six subscales of the CLECS. On three subscales (Nursing Process, Self-Efficacy and Teaching–Learning Dyad), the effect sizes were medium to large, while small effect sizes were observed in the remaining subscales (Table  5 ).

In this study, we demonstrated that first-year nursing students had higher knowledge acquisition when traditional clinical practice in nursing homes was partially replaced by simulation training. The effect size value indicated the practical significance (i.e., a difference large enough to be meaningful in real life) of this result [ 38 ]. However, we observed no significant difference in levels of general self-efficacy. The first-year students scored the simulated environment higher on meeting their learning needs compared with the clinical environment. The effect size values of this result indicated practical significance in the areas of Nursing Process, Self-Efficacy and Teaching–Learning Dyad [ 38 ].

Supportive guidance in linking theory to practice is vital in learning how to provide quality nursing care for patients [ 39 ]. However, the theoretical component of the nursing curriculum can be overwhelming for students [ 40 ]. Students in nursing home practice placements have reported little time for reflection and care reasoning with their supervisors [ 12 , 41 ]. The supervision tends to be task-oriented and related to routine care, and transferable knowledge is not always recognised by students [ 42 , 43 ]. Ironside et al. [ 10 ] found that students frequently missed cues indicating that the patient situations were more complex than merely completing assigned tasks. The current study found a significant positive difference in knowledge acquisition from clinical practice with simulation training as a partial replacement compared with traditional clinical practice in nursing homes. Supervision by teachers and the time available for reflection in the simulation training may have enhanced the students’ understanding of complex concepts and promoted the self-identification of gaps in knowledge, thus motivating students to further learning [ 42 , 44 ]. Based on the design of the current study, we could not rule out that the requirement of preparing for the simulation training may have affected the results. However, nursing students are expected to be exposed to as well as process knowledge in preparing for clinical experiences in both traditional and simulated environments [ 45 ].

Although the factor of self-efficacy is widely believed to increase knowledge [ 46 ], we observed no significant difference in levels of general self-efficacy between the two groups. Shinnick and Woo [ 47 ] found no correlation between self-efficacy and knowledge in simulation training, nor was self-efficacy a predictor of “good” knowledge scores. In the current study, the general self-efficacy scores in both groups may have been related to the high grades required to be enrolled at the university college where the study was conducted. Prior success in school-related tasks may have contributed to the students’ already optimistic sense of general self-efficacy [ 48 ]. Moreover, the GSE may not have been sensitive or detailed enough to best reveal students’ levels of self-efficacy in managing the care of nursing home patients. An interesting finding in the current study was that the intervention group rated the simulation environment to meet learning needs related to self-efficacy significantly higher than the clinical environment. The reason for this result may have been that the self-efficacy statements in the CLECS pointed more directly to self-beliefs related to patient care compared with the general statements in the GSE. However, prior studies that have examined the impact of simulation training on general self-efficacy using the GSE have reported significant differences in general self-efficacy in the fields of psychiatric nursing, community healthcare nursing, communication and paediatrics [ 49 , 50 , 51 ].

An important step in improving nursing students’ clinical education by a partial replacement of clinical hours by simulation training is to understand how learning needs are met by the two methods. In the current study, the learning needs were rated to be better met in the simulated environment. The CLECS covers different aspects of students’ learning needs from the time they receive a patient through the evaluation of patient care [ 37 ]. We observed that the subscales Teaching–Learning Dyad and Nursing Process had the highest mean differences between the two learning environments. The Teaching–Learning Dyad was defined by Leighton [ 37 ] as the interactive relationship between supervisor/teacher and student in which both have shared responsibility for the learning outcomes, while Nursing Process was described as a systematic patient care approach that involves assessment, nursing diagnosis, planning, implementation and evaluation. It has been reported that students in clinical practice placements may experience a disconnection between the taught versus the observed nursing role, and that they may feel that they are left on their own to learn by trial and failure [ 12 , 40 ]. An explanation for the difference related to the Teaching–Learning subscale may be that in simulation training, support and feedback from and collaboration with the teacher are inherent features [ 27 ]. Furthermore, the current study incorporated academic- and practice-focused simulation training that focused on nursing observations, assessments and evaluation of care, which may have enhanced students’ understanding of the nursing process as a structured approach to care, thereby influencing the scores.

Implications for practice

The unmet learning needs of students should drive changes in traditional practice placement models [ 15 , 37 ]. Our results provide evidence related to knowledge acquisition and meeting learning needs, which may justify the partial replacement of clinical hours in nursing homes by simulation training for first-year nursing students. In planning partial replacements of clinical hours, educators may be guided by tools such as the CLECS in their work to design simulation training that may compensate for learning needs that are not properly met in the clinical environment and thereby potentially negatively affect learning outcomes [ 36 ]. However, the number of clinical practice hours required in nursing education programmes is set by the relevant governing bodies; for example, the European Union directive specifies that 50% of the nursing education programme must be dedicated to clinical practice placements [ 52 ]. Thus, the replacement of clinical hours may demand changes in official clinical requirements. As partial replacement, simulation training also has resource implications [ 22 ]. In addition to a considerable amount of faculty time, scheduling issues and the availability of simulation facilities are challenges faced by educators in implementing simulation training as a partial replacement for traditional clinical practice [ 53 ].

Strengths and limitations of the study

In the present study, differences in knowledge acquisition were measured by a multiple-choice test. Questions have been raised about the appropriateness of using multiple choice as a method of assessing the effectiveness of simulation experiences, as multiple-choice questions tend to assess lower levels of cognitive processing [ 54 ]. A multiple-choice test may not be the best tool to evaluate the potential higher order thinking benefits of clinical education. In the present study, we could not control for the participants’ different experiences in clinical practice, nor could we control the distribution of participants between private and municipal nursing homes, which could potentially have influenced the results.

The loss of participants to follow up was higher in the control group than in the intervention group. The control group participants might have felt less obligated to complete the study because they did not receive anything beyond the traditional clinical practice. Nevertheless, no statistically significant differences in demographics and pre-test scores between the groups that completed both pre- and post-tests were observed. Although the sample size was adequate to support the findings of this study, it could also be viewed as a limitation. The results were derived from a limited sample drawn from a single nursing education institution. Expanding the study to include other nursing education institutions would allow for the greater generalisability of the findings.

The results of the present study showed that the partial replacement of hours of clinical practice in nursing homes by simulation training was positively associated with knowledge acquisition and meeting the learning needs of first-year nursing students. These findings are promising regarding simulation training as a viable partial replacement of traditional clinical practice in nursing homes to improve learning. Our findings may help educators to develop future clinical practice models as well as to inspire further necessary research on integrating simulation training as part of clinical practice placements.

Availability of data and materials

The datasets analysed during the current study are available from the corresponding author upon reasonable request.

Abbreviations

The National Council of State Board Nursing

International Nursing Association for Clinical Simulation and Learning

The General Self-Efficacy Scale

The Clinical Learning Environment Comparison Survey

Promoting Excellence and Reflective Learning in Simulation

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Camilla Olaussen, Simen A. Steindal, Lars-Petter Jelsness-Jørgensen, Hege Vistven Stenseth & Christine Raaen Tvedt

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CO was responsible for the conception and design of the study and the analysis and interpretation of the data. CO also worked on the draughts of the manuscript and completed the submitted version of the manuscript. SAS, LPJJ, IA, HVS and CRT contributed comments and ideas during the process, helping to analyse and interpret the data, as well as to revise the manuscript. SAS, LPJJ, IA, HVS and CRT provided their final approval of the submitted version of the manuscript. All the authors read and approved the final manuscript.

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Olaussen, C., Steindal, S.A., Jelsness-Jørgensen, LP. et al. Integrating simulation training during clinical practice in nursing homes: an experimental study of nursing students’ knowledge acquisition, self-efficacy and learning needs. BMC Nurs 21 , 47 (2022). https://doi.org/10.1186/s12912-022-00824-2

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Simulation Training

Originally published in 2014 by researchers at the University of California, San Francisco. Updated in March 2023, by Jennifer J. Edwards, MS, RN, CHSE, Amy Nichols, EdD, RN, CNS, CHSE, ANEF and Deb Bakerjian, PhD, APRN, FAANP, FGSA, FAAN. PSNet primers are regularly reviewed and updated to ensure that they reflect current research and practice in the patient safety field.

Clinical training for health care professionals has historically relied heavily on learning from actual patients, even for invasive procedures and life-threatening situations. In fact, medicine has had a history of promoting “see one, do one, teach one” that has persisted for decades.

However, considerable evidence documents the dangers posed by inexperienced clinicians and poorly functioning clinical teams, which prompted many to consider other teaching methodologies including simulation. Simulation is not new to healthcare training. There is evidence of surgical skill practice on animal cadavers in the Middle Ages, task trainers and birthing simulators in the 1600 and 1700’s and the first nursing manikin, Mrs. Chase, was developed in 1911. 1 In recent years, the use of simulation in healthcare education has continued to grow, including into the allied health professions . It has emerged as a key component of the patient safety movement and is increasingly being used to improve clinical and teamwork skills in a variety of settings. 1,2 This is based in part on its success in other industries including aviation. Simulation offers a way for learners to gain fluency with skills without risk to patients, and gain experience recognizing and responding to uncommon, high-risk, situations that might not otherwise occur over the course of their training.

When employed properly, simulation-based training allows the opportunity to learn new skills, engage in deliberate evidence-based practice, and receive focused and real-time feedback. The goal of simulation-based training is to enable the accelerated development of expertise, both in individual and team skills, by bridging the gap between classroom training and real-world clinical experiences in a relatively risk-free environment.

Methods of Simulation-based Training

There are several approaches to simulation training and depending on the material being emphasized, simulation curricula may employ one or more of these methods. While technology-enhanced simulation is effective, increasing technological sophistication of simulation may not always be necessary. The learning objectives of the simulation should drive the simulation methods used. Below are common methods and settings for simulation to take place.

Methods of Simulation:

• One method of simulation is to use devices for clinical skills trainings. Known as part-task trainers, these life-like simulators are used to train specific clinical skills. An example would be anatomically correct limb models, which are used to demonstrate phlebotomy skills or placement of intravenous catheters.
• Full-scale simulators are also widely used; the most common example is a full-body manikin. These range from low fidelity, offering anatomic landmarks, to high-fidelity manikins with realistic physiologic responses (such as heart sounds, seizure behavior, responsive pupils, and respirations). These are increasingly used to teach physical examination and other fundamental clinical skills, in addition to more complex clinical response. Almost all healthcare providers experience the use of manikins during Basic Life Support training.

Another frequently used method is to use standardized or simulated patients. Employing trained actors to simulate real patients has long been used to teach basic history taking and physical examination skills, and this strategy is also being applied to teach patient safety skills such as error disclosure . These methods are not mutually exclusive, and successful curricula often use combinations of these approaches.

Simulation can be used in a variety of different settings and the particular setting will often dictate the method selected. Below are examples of settings:

• Simulation centers: Simulations take part in specialized learning centers. Many are designed to replicate the variety of clinical spaces learners work in such as ambulatory offices, operating rooms, and emergency rooms, as well as equipment they work with such as ultrasound machines, task simulators, and virtual surgery simulators.
• Classrooms and skills or task labs: Many organizations do not have a simulation center but can use a classroom, break room, or a skills/task lab for simulation.  While the room may not emulate an operating room or emergency room, part- and full-scale simulators can be set up on tables to demonstrate and practice skills.
• In situ simulation: This approach refers to simulation carried out in the actual clinical environment with the providers who work in that location. It may involve use of part-task or full-scale simulators or standardized patients as well. Because of the potential risks to patient and staff safety in the clinical environment, special care needs to be taken when conducting simulation here, including identification of “no-go” criteria .

Over the past decade, more sophisticated and technologically enhanced settings have been developed. 3-6

• Virtual reality: In this modality, learners are immersed in a highly realistic digital clinical environment, such as an operating room or intensive care unit. Learners physically interact with the environment and each other, standardized patients or digital patients, as they would in real life, using systems that are increasingly complex and technologically sophisticated. This technology also allows for learners to be physically distanced from each other, which could be different rooms in a building or across oceans.
• Augmented reality: a variation of virtual reality in which images are superimposed over the users view of the world. This also offers distance learning approaches.   

Simulation has been successfully applied as formative experiences to develop foundational clinical skills as well as more advanced cognitive, communication and technical skills in both pre-licensure and residency training for medical and nursing students. 7-9 It is also being used for summative learner assessments in the form of Objective Structured Clinical Exams (OSCE), which are a required component of many health professions training programs. 10-11

Simulation and Patient Safety

Simulation training is an effective educational modality, with strong evidence demonstrating improvement in learners’ knowledge, skills, and behaviors and simulation approaches have been shown to improve patient-level outcomes . A classic systematic review of more than 600 studies of technology-enhanced simulation training programs in health care found that technology-enhanced simulation training was associated with improvements in learners’ knowledge, skills, and behaviors, and improved patient outcomes. Virtual reality is being explored for usefulness in teaching team skills, communication, leadership and stress management. The recent evidence on simulation as a modality for teaching nontechnical skills is summarized in a 2018 PSNet Perspective . It is worth noting that some reviews have raised concerns regarding the methodological limitations of many simulation studies, including lack of standardization of training techniques, 12 randomization of participants, 13 and measurement methods 14,15 and highlight this as an area to consider in future simulation research.

Simulation is being widely integrated into teamwork training in a variety of environments, including the emergency department , operating room , and obstetrics units . Teamwork training that incorporates simulation often focuses on improving the ability of multidisciplinary teams to handle acute or emergent situations. Teamwork training with simulation has also been used with non-clinical personnel, such as one study in which non-clinician leadership and management had to respond to a simulated patient safety crisis. Research have shown that multidisciplinary simulation-based teamwork training can yield improvement in participants’ knowledge and skills in teamwork.

Simulation in patient safety has shown reduction in adverse events after targeted simulation training, including medication errors as described in this quality improvement intervention that showed improved nurses’ adherence to medication administration best practices from 51% to 84% . The application of human factors engineering methods to patient safety represents another purpose for simulation. Usability testing, which refers to testing new equipment and technology under real-world conditions, and clinical systems testing can be thought of as a form of simulation designed to identify latent safety issues , workarounds and test workflows, and operational readiness. In fact, advanced technologies have helped to provide learners experiences that integrate challenges such as difficult airway intubations, difficult births, and other technically challenging skills.

Simulation is a useful tool to improve patient outcomes, improve teamwork, reduce adverse events and medication errors, optimize technical skills, and enhance patient safety culture. 2 , 16-19  

Learner Experience

Creating a simulation environment conducive to learning is a key consideration in simulation training. Researchers examined 327 learner narrative accounts of simulation experiences and found that while the majority of respondents focused on the development of knowledge, skills, and attitudes of health practice, a small portion (2%) focused on feelings of humiliation, lack of safety, and embarrassment. 18 According to another review , key features of successful simulation education are those of successful curricula in general: individualized feedback, cognitive interactivity, deliberate practice, and longer duration of the curricula. To maximize learner experience and prevent harm, simulation pedagogy should be considered when developing and conducting simulation and facilitators should be trained in best-practice guidelines.  

Best-Practice Guidelines

As simulation use and research has grown, the need for evidence-based best practice guidelines has emerged. There are several organizations that provide guidelines as well as profession-specific and modality specific standards. Generally, the standards include expectations around simulation design, pre-briefing, facilitation, debriefing and evaluation of simulation experiences, as well as operational and professional development standards. It is recommended that anyone participating in the design and facilitation of simulation activities be familiar with, and trained in, best practices. Below are a few organizations.

• International Nursing Association for Clinical Simulation and Learning (INACSL) has released the Healthcare Simulation Standards of Best Practice .
• Society for Simulation in Healthcare (SSH) is an accreditation body for simulation programs.
• American College of Surgeons sets standards for simulation-based surgical education and training. They are also an accrediting body for simulation centers.
• Association of Standardized Patient Educators focuses specifically on simulations involving standardized patients.
• The Interprofessional Education Collaborative (IPEC) publishes Core Competencies for Interprofessional Collaborative Practice , including competencies regarding interprofessional simulations.
• The Committee on Accreditation of Education Programs for the Emergency Medical Services Professions ( CoAEMSP) has released simulation guidelines and recommendations for EMS education.

Current Context

In 2015, the National Council of State Boards of Nursing (NCSBN) released their national simulation study, demonstrating that high-quality simulations could be used to successfully replace up to 50% of traditional nursing clinical hours. 20 Currently, implementation varies by State, but several allow for 25-50% of nursing clinical hours to be replaced by simulation. The American Association of Colleges of Nurses recently published updated “Essentials”, a framework for the preparation of baccalaureate, master’s, and doctoral nurses that focuses on competency-based education. The new essentials document encourages simulation as a valid and reliable element of nursing education that supplements and even enhances certain aspects of direct patient care. 21  

In medical education, all graduating medical students are required to complete a simulated patient encounter to pass the United States Medical Licensing Examination. The Accreditation Council for Graduate Medical Education requires that residency programs provide simulation training, although the specific requirements vary between specialties. The American Board of Anesthesiology requires practicing anesthesiologists to complete a simulation course in order to maintain board certification, but this requirement is not present for other specialties. A WebM&M commentary discusses emerging approaches to simulation, including virtual reality and other technological advancements, as well as the potential for using simulation to assess and remediate individual clinician performance issues .

Jennifer J. Edwards, MS, RN, CHSE Director of Clinical Simulation and Assistant Clinical Professor Betty Irene Moore School of Nursing UC Davis Health

Amy Nichols, EdD, CNS, CHSE, ANEF Associate Editor, PSNet Associate Dean for Academics and Clinical Professor Betty Irene Moore School of Nursing UC Davis Health

Deb Bakerjian PhD, APRN, FAANP, FGSA, FAAN Co-Editor-in-Chief, PSNet Interim Associate Dean for Practice and Clinical Professor Betty Irene Moore School of Nursing UC Davis Health

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This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this report’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report. View AHRQ Disclaimers

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Using simulation exercises to improve student skills and patient safety

Aby Mitchell

Lecturer, Public Health, Health Promotion and Primary Care, University of West London

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Georgiana Assadi

Lecturer, Mental Health Nursing, University of West London

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The COVID-19 pandemic has affected the delivery of nursing training in higher education and how workforce development programmes are delivered. Using simulated practice is an opportunity for experiential and immersive learning in a safe and supported environment that replaces real life. This article discusses the use of simulation in nurse education to improve patient safety.

The current COVID-19 pandemic has had a significant effect on the delivery of nursing training in higher education and how workforce development programmes are delivered ( Health Education England (HEE), 2020 ). This has created a need to transform and adapt current provision to resolve the impact on education and training. In recognition of this, current Nursing and Midwifery Council (NMC) emergency standards offer a maximum of up to 300 hours of simulated learning out of the overall 2300 practical learning hours where clinical practice is not possible ( NMC, 2021 ). The additional simulation hours are considered to be an effective, alternative way of learning, enabling flexibility in practical learning and supporting students in progressing their studies ( Royal College of Nursing (RCN), 2021 ). This presents significant challenges in higher education, both in terms of resourcing and capacity, availability of practice assessors, ensuring proficiencies are assessed in a meaningful way that replicates clinical practice and improving patient safety.

In education, simulated practice is an opportunity for experiential and immersive learning ( Aggarwal et al, 2010 ). It is defined as:

‘A technique to replace or amplify real experiences with guided experiences, often immersive in nature, that evoke or replicate substantial aspects of the real world in a fully safe, instructive and interactive fashion.’

This term broadly includes a wide spectrum of modalities, inclusive of immersive technologies. Immersive technologies are used to create distinct experiences by merging the physical world and/or simulated reality. Simulation and immersive technologies are not new concepts in healthcare education ( HEE, 2020 ).

Simulation theory

The acquisition of appropriate competence is the main objective of nurse education ( Díaz Agea et al, 2019 ) and simulation has grown in popularity over several years, challenging nurse educators to move away from traditional didactic teaching methods. Using simulation as an education platform is congruent with the pedagogical philosophy underpinning the education of current nursing students. The simulation experience in nurse education is characterised by an environment that is experiential, interactive, collaborative and learner centred ( Jefferies, 2015 ). Underpinned by experiential learning theory ( Kolb, 2014 ), simulation allows students to engage directly with an authentic situation and reflect on an observation, noticing what has happened and relate this to past experiences. This enables abstract conceptualisation and active experimentation to test new ideas and hone new skills in a safe environment.

Creation of a simulated environment requires the establishment of trust, between both the facilitator and participant, to share responsibility for maintaining this environment. This enhances the quality of the simulation experience through ‘buying in’ to the authenticity of the experience and suspending disbelief ( Jefferies, 2015 ). The dynamic interaction between the facilitator and participant creates an organic process whereby the facilitator responds to the participants' and group's needs during the simulation experience, adjusting educational strategies or timing of activities. The facilitator provides appropriate feedback in the form of cues (during) and debriefing (toward the end) of the simulation experience ( Jefferies, 2015 ). This subsequently helps to promote student engagement, interaction and psychological fidelity within the simulation experience ( Kiat et al, 2007 ; Leighton and Sholl, 2009 ; van Soeren et al, 2011 ).

The outcomes of simulation can be separated into three areas:

• Participant outcomes
• Patient (care recipient) outcomes
• System outcomes.

Previous literature has tended to focus on participant outcomes, including reaction (satisfaction, self-confidence), learning (changes in knowledge, skills, attitudes), and behaviour (how learning transfers to the clinical environment) ( Jefferies, 2015 ). However, there is emerging literature considering the health outcomes of patients (care recipients) who receive care from professionals trained using simulation, the cost-effectiveness of simulation training and changes in practice from a participant, patient and system perspective as a result of simulation ( HEE, 2020 ).

There are three broad domains in which simulation can be used in nurse education ( Table 1 ).

Principles of simulation that contribute to improving patient safety

Patient safety is the absence of preventable harm to a patient during the process of health care. The first NHS national patient safety strategy was published in July 2019. It is integral to the NHS definition of quality care and underpins all areas of practice. Patient safety is described as maximising the things that go right and minimising the things that go wrong ( NHS England/NHS Improvement, 2019 ). The strategy emphasises the need to build and strengthen a patient safety culture in the NHS, taking a systems-based approach to understanding and improving patient safety. One of the key components of this strategy is to strengthen the existing curricula and lifelong learning guidance for all students and health professionals through education and training in patient safety, human factors and safety management. Simulation can play a key role in underpinning both the patient safety strategy and the syllabus. The use of simulation in training and education provides professional bodies, clinical practitioners and patient groups with the opportunity to examine and redesign systems and processes of care with consideration to human and ergonomic factors relevant to health and care transformation ( HEE, 2020 ). Several studies have highlighted the success of simulated learning environments in improving students' critical thinking skills, an opportunity to problem-solve and practice complex skills in a non-threatening environment ( Sanford, 2010 ; Khalaila, 2014 ).

The use of simulation allows for the creation of scenarios that combine the theory and practice behind the clinical skill/s being learnt, with consideration of a variety of human factors that make up the clinical environments ( HEE, 2020 ). When considering how simulation can contribute to improving patient safety, it is vital to consider the following key areas.

‘Practise first’ mitigates actual patient harm

Simulation allows students to ‘practise before doing’ and to mitigate the risk of harm to a patient when a procedure or assessment is conducted for the first time as there is no ‘real patient’ involved ( Kim et al, 2016 ). It also promotes an increase in confidence and competence in students ( Al Gharibi and Arulappan, 2020 ), which is key in not only the professional and personal growth of students, but also ensures safety in future interactions with patients.

Interprofessional working

Simulation is a medium whereby interprofessional learning can be facilitated to allow students to develop their clinical skills while working in tandem with students from other fields or professional backgrounds to support a patient in any given scenario. This way of learning is very much in line with the view of having fully integrated care systems within the NHS, which have been shown to increase patient satisfaction and the quality of care individuals perceive that they receive ( Baxter et al, 2018 ). Integrated care through working with other professionals has been shown to have positive effects on patient safety in a variety of ways, such as reducing the rates of emergency hospital admissions for individuals over 65, having minimal delays in regard to transfers of care and a reduction in the number of hospital beds used for admissions for individuals aged 65 and over ( Thistlethwaite, 2011 ). The ability to facilitate student exposure to this multidisciplinary way of working early in their training aims to reduce the likelihood of siloed working once qualified, which will ultimately equate to better, safer patient care being provided.

Resilience building

Simulation offers the opportunity for educators to immerse students in varying situations that can promote not only the learning of ‘hands on’ skills, but also of analytical skills that are key in reducing patient safety events ( HEE, 2020 ). Factors such as organisational cultures, system or process issues and communication between professionals are aspects that can be explored in a safe environment. A facilitator/educator can guide the learning session and the post-session de-brief to challenge poor practice, ask students to think about their role or the systems they work in and, most importantly, consider possible areas for change or innovation in themselves or the environment they work in to promote patient safety. This process of using ‘real life’ examples to explore difficult scenarios within a simulated environment, such as untoward patient safety events, can help students to build resilience during their nursing programme for working in a clinical area ( Walsh et al, 2020 ).

Communication

In simulated practice, communication is a key aspect of the learning process and contributes to the development of participants' communication skills. Communication can be viewed as an ‘omnidirectional diachronic process’ ( van Ruler, 2018 ). This promotes the development of meaning through the dynamic interaction between varying factors such as the environment in which the communication is occurring and the relationship between the sender/s and receiver/s of the communication. The complexity of teaching and learning such a skill is evident. This complexity is also emphasised in Annexe A and Annexe B of Future Nurse: standards of proficiency for registered nurses ( NMC, 2018 ), which asks that nurses have certain communication skills in relationship management, and are able to perform certain nursing procedures in which communication forms a key part of safety.

Through the use of simulation, students are able to develop their individual and relational communication skills in a safe and supported environment in a variety of ways that directly link to patient safety ( NMC, 2018 ).

Simulated practice event

Considering these reported benefits of simulated practice, the authors of this article lead on the development and facilitation of an immersive ‘crisis’ event for third-year nursing and midwifery students as a means of applying the theoretical strengths of simulation learning directly into teaching practice (see Table 2 ).

The ‘crisis’ event was developed with a focus on taking a multidisciplinary approach to simulation and was designed for students to work in groups of six in a hypothetical crisis. Students were exposed to four main activities within the simulation, which focused on the themes of teamwork, communication, patient safety and effective debriefing.

First, the students were welcomed into a ‘briefing room’ where they watched a video that was created to provide a backstory to the crisis developing around them. Then the students were taken to the ward simulation suite where they were required to assess the patients on the ward, plan the appropriate treatment/care considering what they observed and assessed and, where appropriate, escalate concerns to a ‘nurse in charge’ figure (whose role was played by a member of the teaching faculty). The ‘patients’ in the simulation were service users and actors. The students were then guided to a room with table and chairs where they had the chance to debrief as a group, before being joined by two members of the faculty who facilitated a debrief session after a period of time. Figure 1 highlights the various areas students were guided through as part of the immersive simulation crisis event and Figure 2 contains pictures of these areas.

The simulation event was a hypothetical crisis event acted by five service users, each presenting with different clinical symptoms. Possible scenarios included ectopic pregnancy, sepsis, anaphylaxis, acute myocardial infarction, choking and assessing the mental state of an individual with dementia. The simulation lasted 20 minutes and students were in groups of six to eight. Students were expected to assess the patients, treat if possible and escalate to the medical team.

After students took part in the facilitated debrief, they were asked to provide feedback in a final room before finishing and leaving the session. From the feedback provided by students (as detailed in Table 2 ) a link between the method of interaction planned and the overarching themes explored relating to patient safety can be made. Additionally, considering the feedback and evaluation provided by students, a decision was made to roll out the immersive simulation ‘crisis’ event across all third-year nursing and allied healthcare courses including continuing professional development and bespoke trust training. Despite this, there continues to be a need for further research to add to the existing body of knowledge of using simulation and immersive technologies in healthcare education, with a particular consideration to patient safety and how its effects might be measured in relation to clinical practice.

Within the context of health care today there is a focus on a system-level approach to changing the culture of healthcare provision that holds integrated care at the forefront of achieving this. Through immersion and authenticity, simulated practice offers the opportunity for educators to support students in applying theoretical concepts, developing their skills and critically reflecting on existing approaches within health care in an environment that is safe and supportive for them, and for the patients they will be supporting in the future.

• Simulation offers the opportunity for educators to apply theoretical concepts and develop new skills in their nursing students
• Simulation allows students to critically reflect on their approaches and receive feedback from service users regarding quality of care and patient safety
• The increased use of simulation in nurse education is an opportunity to create new experiential and immersive learning environments

CPD reflective questions

• How could you use simulation and immersive learning in your area of practice?
• Think about your current training provision, how could this be adapted?
• How has the use of simulation and immersive training improved patient safety in your clinical area?

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The Role of Simulation in Nursing Education

Simulation in nursing education has become an increasingly valuable teaching tool. Not only do simulations allow students to problem-solve and apply clinical knowledge in a safe, low-stress environment, but simulated learning modules also allow students to practice what they’ve learned without needing to worry about making mistakes that could harm patients.

From virtual and online environments to hands-on learning with full-body, computer-controlled mannequins, opportunities for simulation-based training are as vast as they are beneficial.

Professionals interested in learning about how to teach the next generation of nurses in virtual and simulated environments should start by developing the knowledge needed to become a nurse educator. An advanced nursing degree with a concentration in nurse education can prepare graduates with the necessary skills to shape the future of nursing.

What Is Simulation in Nursing Education ?

Simulations provide students with learning opportunities that extend beyond traditional classroom instruction. For example, unlike hands-on learning in a clinical environment, where nursing students may only encounter patients with a limited number of medical issues, virtual simulations are designed to mimic a wide variety of simple and complex clinical situations.

In addition to increasing variabilities in training, virtual learning environments ensure that real patients aren’t exposed to unnecessary risks.

Common Types of Nurse Simulation Training

Today’s nursing students are frequently exposed to a wide array of scenarios in nurse simulation training. The most common types of nurse educator tools include the following:

High-Fidelity Mannequins

High-fidelity mannequins are full-body lifelike mannequins designed to physiologically respond as if they were real-life patients. They have heart sounds and pulses and can mimic other bodily functions. These mannequins can help students provide intravenous infusions and detect changes in patients’ conditions.

Low-Fidelity Mannequins

Unlike high-fidelity mannequins that appear quite lifelike, low-fidelity mannequins are less realistic and are used to help students practice basic skills. For example, CPR certification courses use Resusci Anne, a silicone mannequin that consists of a head and torso, to teach students how to open patients’ airways and perform chest compressions. 

Partial-Task Simulators

Partial-task simulators are lifelike models of specific parts of anatomy such as the arm, leg or torso, designed to help students gain proficiency in a specific skill. Partial-task simulators can teach students how to draw blood, insert an IV tube or a hep-lock and perform the Heimlich maneuver, among other crucial tasks.

Role-Playing

In role-playing simulations, students take turns assuming the role of a patient or a health care provider. This type of experiential learning allows students to act out various scenarios and use their critical thinking skills. It also requires students to closely examine complex and in some cases controversial medical scenarios and apply their knowledge to solve specific problems. 

E-learning modules allow students to participate in computer simulations from anywhere they have access to an internet connection. These simulations can teach students how to use specific pieces of medical equipment or provide virtual patient care simulations designed to help students improve their competency. 

Volunteer Patients

In this type of simulation, patients volunteer to help students practice various skills, such as asking for informed consent, asking for a patient to provide their medical history and explaining what patients can expect during a particular procedure. Volunteer patients are also used to help nursing students refine nursing soft skills .

Benefits of Simulation in Nursing Education

A 2021 study in Acta Informatica Medica found that nursing students who participated in simulation in nursing education to practice their decision-making and clinical skills in a protected environment had an enhanced sense of security, which in turn, improved their confidence and self-esteem. The study also found that the further development of simulation-based learning tools can “significantly help the efforts made by students to become integrated and successful healthcare professionals.”

The National Council of State Boards of Nursing agrees that simulation training for nursing students is highly beneficial. Examples of some of the benefits of simulation in nurse education include the following:

• They help students develop clinical reasoning capabilities.
• Simulations train students to become adept in providing care to patients and their families.
• Students are provided with immediate feedback and an opportunity to try again if needed.
• Virtual and mannequin-based simulations can be manipulated to mimic complex medical situations.
• Unlike traditional, classroom-based study, simulations provide students with experiential learning opportunities.
• Simulations allow learners to practice their skills in a safe, controlled environment in which they can make and learn from mistakes, without needing to worry about affecting patient outcomes.
• Learning modules are designed to become harder as curriculum topics become more complex.

Earn Your MSN to Teach the Next Generation of Nurses

Professionals interested in pursuing their passion for educating future nurses must begin with a comprehensive understanding of how to develop lesson plans that encourage professional development. The online Master of Science in Nursing with a Nurse Educator concentration from Walsh University is designed to prepare graduates to teach in a variety of in-person and virtual settings. 

Are you ready to take the next step toward becoming a nurse educator? Discover how the online Master of Science in Nursing, Nurse Educator program at Walsh University can provide you with the teaching strategies to succeed. 

Recommended Readings

Why Get a Master’s in Nursing Education? Why Nurse Educators Are Needed to Address the Nursing Shortage What Tools Do Nurse Educators Use? Sources:

• Acta Informatica Medica, “Simulation in Clinical Nursing Education”
• Healthy Simulation, Nursing Simulation | About & Resources
• Healthy Simulation, Role-Play: A Healthcare Simulation Strategy for Teaching Problem-Solving, Communication, and
• Self-Awareness
• Healthy Simulation, Simulation in Nursing Education
• NCSBN, Simulation Study

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Post-Tribune

Nursing students in teams use simulators to compete in real-world scenarios, ‘everybody is kind of thinking together’.

Students in scrubs surrounded the bed of a “patient” Thursday at Indiana University Northwest as they took vitals, asked questions and reviewed the patient chart to remedy the patient’s complaints.

They gathered by the hospital bed on the stage at Bergland Auditorium in teams of three to test their nursing skills in a timed round-robin competition as part of the annual SIM Wars, a simulation competition that highlights what the students have learned in the week leading up to finals week.

Four teams each consisting of a senior, junior and sophomore nursing student appeared on stage one at a time to tackle the scenario and resolve the patient’s concerns. The teams were selected in advance, Crystal Shannon, dean of the College of Health and Human Services and director of nursing, said. Students did not know what scenario they would be tasked with handling.

“These are patient care scenes,” Shannon said. SIM Wars are a fun way to let students demonstrate what they have learned in a friendly competition outside of the regular classroom. It builds what she described as “an active robust (nursing) simulation program.”

In the first round, a med-surg scenario is described to the team members, who must determine what is happening with the resources they would find in a typical hospital room interaction.

“They don’t tell us what they are going to do, they are showing us,” Shannon said.

If they are successful treating the condition the patient is presenting with, the simulation ends. A countdown clock on a large screen behind the mock hospital room ticking down from 15 minutes provides the backdrop for students competing and watching.

All four teams were able to master the scenario before the time ran out, with the two top-performing teams moving on to a more challenging simulation. The top-performing team in that scenario wins SIM Wars.

During the break between each group, the atmosphere remained festive and competitive as everyone participated in a Jeopardy-style game about nursing. Each grade level competed to gain the title, answering questions in categories including assessment, perfusion and oxygenation, and nursing processes among others.

Shannon said before SIM Wars, instructors recruited the 12 challenge participants. Most of the 200 students in the nursing program attend the event, which is a run-up to finals week beginning Monday.

Junior Marrin Brandt of Valparaiso, sophomore Jackson Mielczarek of Lowell and senior Dylan Rouhselang of Valparaiso were on one team, while senior Latoya David of Griffith, sophomore Valerie Mendoza of Hammond and senior Kayla Cheeks of Portage were another of the four teams participating.

“We paused a lot,” Mielczarek said critiquing his team’s performance. “I was kind of nervous.”

“You couldn’t think about the crowd,” Rouhselang said. Overall they said things went pretty well once they got past their nerves.

“I think we did good,” Mielczarek said.

Mendoza said the competition helped participants act quickly and think critically.

The simulations also help teach students to look at the small things that they may not think are the problem, Cheeks said.

David said her teammates did well during the competition and thought of things that she on her own did not.

“It’s better having a team. Everybody is kind of thinking together,” she said.

Brandt said the simulations were helpful, but she wished the challenge was in the middle of the semester and not the week before finals.

“I like the simulations. I think they are super helpful,” Brandt said.

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