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Simulation-Based Learning: No Longer a Novelty in Undergraduate Education

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Michelle Aebersold, PhD, RN, CHSE, FAAN

Abstract

Simulation, once the domain of those faculty who enjoyed the technical aspects of using computerized mannequins, has now moved to center stage in nursing education. Nursing programs realize that they can no longer afford to consider simulation as merely an 'add-on.’ Simulation today includes role play, standardized patients, virtual simulation, and computerized mannequins. It is now imperative to integrate simulation throughout the entire curriculum. Today, simulation allows students to learn skills; develop clinical reasoning abilities; and to become competent in caring for patients/families in a safe environment. The variety of simulation-based learning options can offer a way to replace traditional, and often hard to find, clinical experiences. In this article, the author describes the background, theoretical basis, and current uses of simulation; reports on simulation effectiveness in nursing; shares educational strategies to enhance effectiveness; and considers simulation methods and feedback and debriefing strategies. The conclusion addresses simulation evaluation, and the future of simulation in nursing education.

Citation: Aebersold, M., (April 3, 2018) "Simulation-Based Learning: No Longer a Novelty in Undergraduate Education" OJIN: The Online Journal of Issues in Nursing Vol. 23, No. 2.

DOI: 10.3912/OJIN.Vol23No02PPT39

Key Words: undergraduate education, simulation, virtual reality, simulation standards, mannequins, patient safety, NCLEX, NCSBN, research, fidelity

...simulation-based learning has matured as an educational strategy and research about this area has increased. Simulation in undergraduate (UG) education has become one of the new policy areas to which leaders in both nursing education and practice will want to pay careful attention. As the nursing shortage increases, the number of faculty available to educate new nurses decreases. The number and availability of clinical sites is diminishing (American Colleges of Nursing, 2017), and we will need to rely increasingly on simulation to fill the gaps. The good news is that simulation-based learning has matured as an educational strategy and research about this area has increased. However, there remains much work to be done.

In this article, I will briefly discuss the background of simulation; address the theoretical basis, and the current uses of simulation; report on simulation effectiveness in nursing; and share educational strategies to enhance simulation effectiveness. I will discuss simulation methods, including feedback and debriefing strategies; consider simulation evaluation; and share my insights on the future of simulation opportunities for undergraduate nursing education.

Simulation Background

[Simulation] is not defined by a technology but rather an educational approach grounded in learning theories. Simulation-based education is an educational or training method that is used to “replace or amplify real experience with guided experiences” (Gaba, 2004b, p.i2). It is not defined by a technology but rather an educational approach grounded in learning theories. Simulation is meant to replicate aspects of the real world in an interactive manner that allows learners to be immersed in the learning environment (Gaba, 2004b; Jeffries, 2012). Aviation and the military have used simulation to train pilots and personnel in both skills and safety-related behaviors (e.g., communication and teamwork), for many years (Aebersold, 2016). Historically, simulation in nursing has been used primarily in undergraduate (UG) education to teach nursing skills.

The first mannequin was a life-size doll named Mrs. Chase. She was built in 1911 by a doll maker, Martha Jenkins Chase, to train nurses to dress, turn, and transfer patients (Weir, 2012). Some early 'sim labs' were called demonstration rooms, the skills laboratory, or the nursing laboratory (Nickerson & Pollard, 2010). Nursing students would practice on mannequins, such as Mrs. Chase, or on each other by using various training devices to learn to administer injections, insert a nasogastric tube, and other basic nursing skills.

In the 1990s there was a significant change in the world of educational simulation, a change that impacted the nursing skills laboratories. Companies, such as Laerdal™ and Medical Education Technologies, Inc. (METI), developed affordable, high fidelity simulators based on the earlier pioneering work of David Gaba and others (Gaba, 2004a). METI was bought out by CAE™ which is now a major producer of high fidelity simulators, along with Gaumard Medical™, and Laerdal™. Subsequently, nursing education has moved from a traditional skills laboratory into the world of high fidelity simulation (HFS).

...although a sophisticated, computerized mannequin can produce a high fidelity simulation, so also can an actor who is playing a role. Many think of high fidelity simulation as highly sophisticated, computerized mannequins that can mimic the body’s physiology. However, it is important to recognize today that, although a sophisticated, computerized mannequin can produce a high fidelity simulation, so also can an actor who is playing a role. Fidelity refers to realism or the ability to replicate the real ‘thing’ that the simulator or actor is representing. Therefore, high fidelity simulation can be done with a high fidelity simulator (i.e., a computerized mannequin) or a live person. There are a variety of simulators available, as well as several different simulation methods. The most common methods utilize computerized mannequins, role-play, standardized or simulated patients, and virtual simulations. There is now a Healthcare Simulation Dictionary, which includes all commonly used terms in simulation (Loprieato et al., 2016).

Theoretical Basis for Simulation

Since the 1990s there has been a tremendous amount of knowledge and research in the area of simulation-based learning. Some very important, landmark studies have been completed. Simulation has become a cornerstone of UG nursing education. It is important to understand benefits and policy implications of this shift.

Simulation-based experiences (SBEs) most often occur in a simulation laboratory setting in which the UG students come for a defined period of time and engage in activities specifically designed around a set of learning objectives. These activities are developed into simulation scenarios. The scenario contains the learning objective, the patient information (e.g., background, current condition, medications, and other relevant information), actor scripts as needed, information for the high fidelity simulator, a timeline for the unfolding of the scenario, cues needed by the facilitator to help the action flow along, and other essential information to ensure that the simulation-based learning education experience is successful.

Simulation-based education is a learner-centered approach, grounded in learning theories based on constructivism. Several educational learning theories and conceptual models guide development of SBEs. Some of the more popular ones are described below. Simulation-based education is a learner-centered approach, grounded in learning theories based on constructivism. As such, learners create their own reality and truth. To support this type of learning, activities include discussion, self-reflection, and questioning so that learners can engage actively in the learning process (Kriz, 2010).

One popular learning theory often used to guide and develop SBEs is Kolb’s Experiential Learning Theory (ELT) (Kolb, 1984). This theory has four steps (concrete experience, reflective observation, abstract conceptualization, and active experimentation). These steps form a continuous cycle. As applied in SBEs, concrete experimentation occurs initially when learners or students engage in a simulation scenario, such as caring for a simulated patient (i.e., a high fidelity mannequin) who is experiencing a stroke. After the scenario ends, students engage in reflective observation as they debrief and reflect on their performance during the simulation and identify any gaps. The next step is abstract conceptualization. During this step, or phase, the facilitator of the SBE helps learners create or adapt their mental model to incorporate what they have learned. This is where learning occurs and where knowledge can transfer into practice when the next opportunity arises. The process in which learners put newly gained mental models into practice is referred to as the active experimentation step (Zigmont, Kappus, & Sudikoff, 2011).

An additional theory is the NLN/Jefferies Simulation Theory (Jeffries, Rodgers, & Adamson, 2015). This theory evolved from the NLN/Jeffries Framework (Jeffries, 2012). It includes context, background, and simulation design characteristics. These elements lead into the simulation experience itself, which includes a dynamic interaction between the facilitator and the learner through the use of appropriate educational strategies. Outcomes occur in three areas: the system, the patient, and the participant. Adamson (2015) conducted a systematic literature review that included 153 articles; findings from this review supported the major components of the NLN/Jeffries (2015) framework.

Current Uses of Simulation in Undergraduate Education

...faculty have integrated simulation into many different undergraduate courses. A review of current literature demonstrates that faculty have integrated simulation into a many different undergraduate courses. This section will describe how simulation has already been integrated into a number of nursing programs via undergraduate course content that includes mental health, end-of-life care, mass causality situations, anatomy, and intradisciplinary and interdisciplinary communication (virtual simulation).

Mental Health
In the mental health undergraduate curriculum, use of standardized or simulated patients (SPs) (trained actors) has been found to reduce student anxiety and develop interview and therapeutic communication skills, thus increasing student confidence prior to the clinical experience (Doolen et al., 2014). Another use of simulation in mental health nursing is to involve students in 'voice-hearing' simulations, to give them an opportunity to appreciate what it is like to live as a patient with auditory hallucinations, and to help them understand the behavioral risks associated with these conditions (Orr, Kellehear, Armari, Pearson, & Holmes, 2013).

End-of-Life Care
Simulation at the UG level also helps students learn to provide appropriate end-of-life (EOL) care for patients and families. Students receive didactic information in class (Allchin, 2006), yet seldom have an opportunity to care for dying patients during clinical rotations. Through simulation, however, students are exposed to EOL in several ways.

Students agreed that this type of multi-patient simulation experience improved their ability to prioritize patient needs, resolve conflicts, and track multiple responsibilities. One UG EOL simulation experience centered on an elderly patient with lung cancer that had metastasized to the liver and bone. This patient was admitted for palliative care (Fabro et al., 2014). After students participated in this scenario, caring for the patient and family with the goal of managing the patient’s pain and the family’s grief, they completed a qualitative questionnaire about their experience. Students described their experiences as awkward and uncomfortable, and with feelings of sadness and helplessness. However, they also learned about what a ‘good death’ can look like, and how difficult it can be to administer medications and assess vital signs while the family is crying. Students went on to say that they gained new knowledge and hoped they would remember this experience when they cared for similar patients in the future.

Another multisite study about EOL care considered knowledge, self-confidence, and communication skills among baccalaureate, associate degree, and accelerated baccalaureate degree pre-licensure students. The setting for this simulation was a hospice setting. The 336 students who participated in the simulation demonstrated a significant increase in knowledge, self-confidence, and perceived communication skills (Fluharty et al., 2012).

Mass Causality and Multi-Patient Situations
Simulation has also been used in disaster training for UG nursing students. Collaborating with a local health center to participate in a mass causality event can provide an opportunity for nursing students to experience the role of triage and also for teamwork with other care providers. Austin et al. (2014) found that senior nursing students, under the guidance of pediatric nursing faculty, were able to successfully participate in a community-wide, mass-causality event that increased their understanding of the disaster response process, role clarity, and teamwork. Additionally, Horsley et al. (2014) have developed a multi-patient simulation to prepare students to care for multiple patients at a time on an inpatient unit. Students agreed that this type of multi-patient simulation experience improved their ability to prioritize patient needs, resolve conflicts, and track multiple responsibilities.

Anatomy
Anatomical simulation is another area of virtual reality that continues to grow. Anatomical simulation is another area of virtual reality that continues to grow. Some schools are investing in virtual anatomy tables that allow students to visualize patient anatomy by ‘virtually dissecting’ patients (Choi, 2013). Future technology in this area will include immersive virtual reality and augmented reality. Immersive virtual reality is currently represented by two major companies, Oculus, which makes the Oculus Rift, and HTC, which makes the Vive. Websites for the Oculucs Rift, HTC, Vive, and other Virtual Resources (VRs) are presented in Table 1.

These resources use head-mounted displays to immerse the wearer into a three-dimensional, virtual world that completely visually isolates them from the physical world. The devices can be used for skills training (e.g., practice to insert a small bore feeding tube or perform a sterile procedure). Augmented reality enables a virtual object or image to be projected into the room or onto an object, such as a simulator. Microsoft® has developed the HoloLens, which is the current product in this market. This is very new technology and currently is at the 'proof of concept' testing stage.

Table 1. Virtual Resources

Product

Website

Oculus Rift

https://www.oculus.com/

HTC Vive

https://www.vive.com/us/

Microsoft HoloLens

http://www.microsoft.com/en-us/hololens

vSim

http://thepoint.lww.com/vsim

Shadow Health

https://www.shadowhealth.com/

Google Cardboard

https://vr.google.com/cardboard/

Google Daydream

https://vr.google.com/daydream/

Intra and Interdisciplinary Communication (Virtual Simulation)
Many educational institutions have developed islands into spaces where faculty can engage in virtual simulations. Virtual simulations are a small but growing part of UG simulation experiences. Some virtual products currently in use include: Second Life® (Linden Labs); vSim® for Nursing (Laerdal); and Shadow Health™. Second Life®is a three-dimensional virtual world built by Linden Labs that enables people to visit as avatars. This is done by downloading a free computer program, creating a free account, selecting an avatar, and traveling to various ‘open’ spaces called islands. Many educational institutions have developed islands into spaces where faculty can engage in virtual simulations (Aebersold, Tschannen, Stephens, Anderson, & Lei, 2012).

A systematic review of studies published on the experience of using Second Life® in UG education found that although positive learning can occur, Second Life® is an emerging technology; further research is needed to enable this platform to become a common teaching strategy (Irwin & Coutts, 2015). Virtual simulations using Second Life® have been an acceptable method for teaching students from different professional backgrounds to work together as a team to deliver difficult news to patients. Caylor, Aebersold, Lapham, and Carlson (2015) studied 21 students from nursing, pharmacy, and medicine who participated in a multi-professional simulation in which they had to disclose to a ‘virtual patient avatar’ that a medication error had occurred. Students rated the experience as realistic, effective, and a convenient platform for learning.

Early research has shown that students view these experiences positively... For comparison vSim® and Shadow Health™ are both commercial products that contain pre-built cases and activities. vSim® is a computer simulation that allows students to care for patients with a variety of healthcare needs. This product includes scenarios for students taking courses in medical-surgical concepts, maternal-child health, gerontology, fundamentals, health assessment, and pharmacology. Because this technology is very new, there are few published studies evaluating its use. However, some UG programs are counting simulation technologies, such as vSim, as part of clinical replacement hours (personal communication, B. Cambridge, September, 2016). Early research has shown that students view these experiences positively and recommend their use (Foronda et al., 2016). Another study found that the addition of vSim in a fundamentals nursing course increased student knowledge significantly when compared with that of other students who received only the usual course content (Gu et al., 2017).

Another commercial, virtual-simulation experience is CliniSpace™, an online, virtual, clinical environment developed with Unity, an open-source game design platform. CliniSpace™ has developed a game-like environment where nurse and physician avatars can interact and deliver care in patient care units. Foronda et al. (2014) used this virtual world to pilot a simulation with UG students to determine whether simulations focused on handoffs would improve their skills. After a series of two simulations, significant improvement was noted in student scores on the Identify, Situation, Background, Assessment and Recommendation (ISBAR) rating sheet, thus supporting the ISBAR process as a safe process for transferring patient information in clinical handoffs.

Simulation Effectiveness to Date

Nehring and Lashley (2009) published their 40-year review of simulation, finding that simulation was used in nursing education in many forms, including standardized patients, computerized instruction, and mid- and high-fidelity simulators (HFSs). They predicted that the use of simulation would grow in nursing education; yet they cautioned that standards needed to be developed to ensure that quality education would be associated with its use.

Simulation-based education today has matured to the point where we have good evidence to demonstrate effectiveness. Simulation-based education today has matured to the point where we have good evidence to demonstrate effectiveness. A recently published ‘review of reviews’ found seven review articles on HFS in the last ten years that focused on UG nursing education and HFS (Doolen et al., 2016). Of the five integrative reviews, three validated simulation as an effective teaching-learning strategy in pre-licensure nursing education. Behaviors addressed in these reviews included medication safety, handwashing, communication related to safety, knowledge acquisition, and knowledge transfer. Also noted in these reviews, however, were a lack of randomized studies, few valid and reliable measurement tools, and overuse of 'confidence' as an evaluation measure. To date, both the topic of pre-briefing and that of debriefing have not been studied sufficiently in nursing.

Another review by Cant and Cooper (2017) found that simulation has become a well-accepted method of learning by students, a method which enables them to reconcile theory with practice. Study outcomes demonstrated the positive impact of simulation on knowledge acquisition, psychomotor skills, self-efficacy, satisfaction, confidence, and critical thinking skills.

For students who had either 25% or 50% of their hours replaced with simulation, there was no difference in NCLEX pass rates or end of program educational outcomes... The most significant research to date to influence nursing education at the pre-licensure level was a two-part study conducted by the National Council of State Boards of Nursing (NCSBN). The first part was a randomized, controlled trial looking at the effectiveness of simulation in UG nursing; the second part was a survey study of the new graduates and their managers during their first six months of employment (Hayden, Smiley, Alexander, Kardong-Edgren, & Jeffries, 2014). This study measured the effect of simulation as a replacement of clinical hours for either 25% or 50% of each school's total clinical hours. The control group could have no more than 10% of student clinical hours replaced by simulation. For students who had either 25% or 50% of their hours replaced with simulation, there was no difference in NCLEX pass rates or end of program educational outcomes when compared with students who had more clinical time. Students also perceived that simulation enabled their learning needs to be met; that they could perform well on tests; that they could synthesize content they had learned; and that they did well in all subject areas (pediatrics, maternal child, mental health, medical-surgical, and community health).

...results demonstrated that clinical hours can be effectively replacement by simulation. Phase two of the study (Hayden et al., 2014) followed students into their first jobs. In this phase, managers were asked to rate the new graduates readiness for practice and overall global competency. That there were no differences between the three groups was important, because these results demonstrated that clinical hours can be effectively replacement by simulation. It also identified best practice methods for conducting those simulations.

After completion of the study, the NCSBN convened a panel of experts in simulation who put forth a set of guidelines (Hayden, et al., 2014). These guidelines were based on the study (Hayden et al., 2014); International Nursing Association for Clinical Simulation and Learning (INACSL); Standards of Best Practice: SimulationSM; and current knowledge of best practice from the study (Hayden et al., 2014). As a result of the study, some state boards of nursing have started to incorporate these recommendations into nursing school guidelines.

As these state boards begin making decisions about how many clinical hours can be replaced, some boards that offered no guidelines in the past have started moving to implement a 25% or 50% replacement with the adoption of NCSBN guidelines. The National League of Nursing (NLN) has also been a significant contributor to the educational and research efforts with simulation. The NLN has published a visionary statement endorsing the study and making some very strong recommendations to deans, directors, and chairs of nursing programs, and to faculty on how best to support and incorporate simulation into UG programs (NLN, 2015).

Educational Strategies that Enhance Effectiveness of Simulation

...simulation done poorly, or poorly integrated into the curriculum, will not be any better than the traditional clinical approach. Simulation has become a significant part of the UG curriculum. It is a theory-based, effective teaching method with a growing body of research evidence support. With nursing schools facing a growing shortage of clinical placements (American Colleges of Nursing, 2017), as well as restrictions on the activities in which nursing students can engage, simulation provides an effective alternative to clinical training. One might argue that simulation can be more effective than the ‘see one, do one, teach one’ model that has often been the mainstay of the clinical teaching model. However, simulation done poorly, or poorly integrated into the curriculum, will not be any better than the traditional clinical approach. Teaching via simulation must be done as carefully as any other new teaching method. It requires a careful, thoughtful approach to ensure success for both students and faculty. The paragraphs below describe a few strategies for such careful and thoughtful approaches.

Curricular Mapping and Integration
To begin, it helps to think about using a curriculum development strategy. Examples of these include the Six-Step Curriculum Development Process for healthcare education (Thomas, Kern, Hughes, & Chen, 2016) which starts with a needs assessment and ends with evaluation and feedback. You can also find other excellent resources at the National League of Nursing-Simulation Innovation Resource Center (NLN-SIRC), including a faculty toolkit that contains curriculum integration information and links to helpful resources (NLN, n.d.). These resources promote simulation not just as something to add to a course, but as a strategy to integrate throughout the entire curriculum.

...it is important to create a curricular map of the concepts and high-level learning... To gain the most value from simulations, it is important to create a curricular map of the concepts and high-level learning occurring in each simulation for each course. This ensures that you are not focusing on the same topics in each simulation (e.g., simulations in pediatrics, maternal health, and community health that all focus around the death of a newborn). Unless each one will teach something novel, or the goal is to ensure scaffolding of learning in a particular area, you are likely repeating something without purpose due to a lack of awareness about what others are doing. A better way to approach this is to meet with key faculty from different courses to explore what is done, or might be done, in simulation, and then determine how student needs can be best met overall. However, there may still be skills or concepts (e.g., patient handoffs or medication safety) which merit repeating in many simulations because they are key skills.

Simulation Outcomes
...it is critical to establish ground rules during the pre-brief period so that students understand expectations. Simulation allows students to practice caring for ‘patients’ in ways that they cannot in the hospital or other settings. Faculty are encouraged to leverage this freedom to give students experiences that they may not get in ordinary clinical settings. For example, faculty can have students play the role of the nurse (not student nurse). Students need to practice the role of the bedside nurse, to include making decisions, calling other healthcare providers, documenting without a co-signer, and administering medications independently. This experience offers students the opportunity to evaluate how well they can perform, while remaining within a safety net. To do this, it is critical to establish ground rules during the pre-brief period so that students understand expectations. They need to know it is okay to make mistakes, and that those mistakes will be discussed during debriefing, giving them the opportunity to learn from the mistakes and consider ways to improve.

Simulation can be incorporated into the curriculum as a way to support student achievement of knowledge, skills, and attitudes (KSA) and competencies needed to attain the overall program goals set forth by the school curricular plan. These goals also link curriculum planning to program accreditation; the National Council Licensure Examination (NCLEX) test outcomes; the Quality and Safety in Nursing Education (QSEN) competencies; The Joint Commission Safety Goals; and other areas. Simulation can be included in either formative or summative assessment methods, as long as faculty are clear with students regarding the goals of a given simulation experience. Developing curricular maps with the simulation scenario, major content, and concept threads is the best way to track what you are doing in simulation. Table 2 offers some specific ideas for incorporation of simulation into the curriculum.

Table 2. Simulation Ideas for Undergraduate Nursing Education

Course

Topic(s) or Concept(s)

Simulation Suggestion

Pediatrics

  • Immunizations
  • Culture
  • Assessment
  • Patient history
  • Create a simulation for students to practice infant assessment in a clinic setting.
  • Create a challenge when parents state they do not want their child to receive vaccinations.
  • Add a cultural dilemma or language barrier.

Pediatrics

  • Asthma
  • Patient handoff/Transitions of care
  • Nurse Role(s)
  • Create an unfolding set of simulations where a school age child has an acute exacerbation of asthma at school. The school nurse follows her asthma action plan, calls EMS and the child goes to the ED. There is a handoff to the inpatient unit or an observation unit where the child receives care.

Maternal Health

  • Laboring mom
  • Bathing
  • Post-partum care
  • Newborn assessment

Students need to understand the care of the laboring mom, so it would be important to learn to care for a mom in labor. For simulation centers that do have access to a birthing simulator there are options such as:

  • Mama Natalie® by Laerdal (less than $1000)
  • Parto Pants™ (Pronto) another low cost solution; worn by a student or SP.

Both allow for normal or complicated deliveries.

Newborn assessment can be done using a newborn simulator or even a doll that is appropriately sized.

Maternal Health

  • Managing obstetrical emergencies
  • Post-partum hemorrhage
  • Teamwork
  • Communication
  • Situational awareness

Conducting a simulation on post-partum hemorrhage is essential in the maternal health curriculum. This simulation can be found in most vendor-offered packaged curriculums or other free resources. This teaches students to recognize and manage an area with a high rate of mortality as well as many other important skills.

Medical-Surgical

  • Cardiac
  • Respiratory
  • Sepsis
  • Stroke
  • Acute MI
  • Patient handoff
  • Medication Management
  • Multiple patient management
  • Communication
  • Critical Thinking

The importance of simulation at the medical-surgical level is focus on:

  • developing student clinical judgment and skills
  • determining how to prioritize assessments
  • gathering data
  • making decisions
  • implementing interventions correctly
  • reflecting about what they are doing

The content is less important. This is not the time to load content that does not seem to fit elsewhere. This is an opportunity to think about key patients for whom it would be great if every student had an opportunity to provide care.

Medical-Surgical or Advanced Medical-Surgical

  • Stroke
  • Focus on a case to assist students to recognize signs of a stroke in a patient who is in the hospital for another problem, such as an elderly man who had a hip replacement and has a history of atrial fibrillation and sleep apnea.

This will teach students to recognize a stroke and learn how to react in a crisis. This type of simulation generally requires a high-fidelity mannequin.

Leadership

  • Impaired nurse
  • Nurse-to-nurse bullying
  • Root Cause Analysis for a Sentinel Event or medication error

In leadership courses, simulation can be used to address topics nurses face on the unit. There are articles and resources available to assist in developing simulation on these topics. Students find it beneficial to learn how to deal with nurse-to-nurse bullying and they need opportunities to role-play these types of strategies.

Simulation Methods

There are many simulation methods from which to choose... The key is selecting the technology or method that provides for active engagement with the learner. There are many simulation methods from which to choose, as evidenced by the review of types of simulation used in various areas. The challenge for faculty and simulation educators is choosing the most appropriate methods. In the Simulation Model for Improving Learner and Health Outcomes (SMILHO), Aebersold and Titler (2014) address this challenge. The key is selecting the technology or method that provides for active engagement with the learner. This links back to the theoretical models upon which simulation is based. If the goal of the simulation is to practice therapeutic communication skills, then using a standardized simulation patient (SP) will be the ‘best’ option. Another option would be to use a mannequin and provide the voice for the mannequin through a microphone placed near the mannequin’s head with the faculty providing the voice. You do not need a sophisticated computerized (i.e., high-fidelity) mannequin. Rather you can use any mannequin; by adding clothes, a wig, and glasses, one can simulate a person.

Standardized or simulated patients can also be effective to play family members in simulations that include role play (e.g., a mom of an infant coming for a well-baby checkup). Students could then interview mom to provide a history for baby. A simulation patient can create tension around immunizations for baby when parents are unwilling to have their child vaccinated. Although students could play this role, younger students often lack the life experiences for effective role play unless they have some background in the specific area or perhaps have been students in the performing arts.

If students are practicing a specific skill, such an intravenous or Foley catheter insertion, you only need a task trainer or a ‘body part’ (e.g., an arm or torso). These allow students to practice the skill and do not tie up mannequins or increase ‘wear and tear’ on expensive equipment. It is best to use mid-fidelity or mid-level mannequins for mid-level students practicing basic scenarios. Although these mannequins often lack more sophisticated features (e.g., chest movement, pupillary response), they can produce vital signs such as lung and heart sounds. They can be used successfully to run many simulations, such as identifying changes in lung sounds during early congestive heart failure or performing a priority assessment. They are also great for multiple patient simulations that may be run in a skills laboratory along with SPs.

Simulation Feedback and Debriefing

... a newer style of debriefing and feedback is emerging that is showing promising results. It is important to note that in simulation experiences, goals and objectives will likely be different from goals in the clinical area. Simulation is intense and there may only be 2 to 4 learning objectives for a short focused simulation. Learning in simulation occurs primarily during debriefing (Cheng et al., 2014; Shinnick, Woo, Horwich, & Steadman, 2011) thus it is important that all debriefing facilitators are trained and use a debriefing framework (Cheng et al., 2014). Most faculty are familiar with common debriefing frameworks; however, a newer style of debriefing and feedback is emerging that is showing promising results. This newer method is based on the deliberate practice work of Anders Ericsson (2004). Deliberate practice and feedback, using a pause and discuss approach, provides instant feedback to learners about a skill they are learning and then they ‘rewind’ and practice that skill again (Eppich et al., 2015). This can be very effective for certain types of simulations, such as cardiopulmonary resuscitation training, where repetition with feedback is important (Hunt et al., 2015).

The concept of debriefing is one of the most studied areas in the field of simulation. Faculty must keep informed about current literature and research. They should receive training about debriefing and practice their skills. It is important for faculty to receive feedback from other facilitators, and also students or learners, when possible. There are excellent tools available to help in this regard, such as the Debriefing Assessment for Simulation in Healthcare (Center for Medical Simulation, n.d.) which offers both faculty and student debriefing versions to provide feedback to the debriefer. Other tools, such as the Simulation Effectiveness Tool (SET), can evaluate student perceptions of the effectiveness of simulation. This tool has been recently modified (SET-M) and has demonstrated good psychometric properties (Leighton et al., 2015).

Evaluating Simulation in Undergraduate Education

... measurement of learning outcomes and transfer of knowledge and behaviors is expected, although still not consistent. Research about the effectiveness of simulation has grown from earlier stages, in which learner self-confidence was the only measure, to the present day where measurement of learning outcomes and transfer of knowledge and behaviors is expected, although still not consistent. The most commonly used evaluation framework in simulation is the Kirkpatrick model of training effectiveness (Kirkpatrick, 1994). This evaluation framework includes four evaluation levels: reaction (satisfaction with the training); learning (increase in knowledge and skills); behavior (the participant performs differently); and results (change is noted). Applying this framework to simulation training provides an effective way to measure how well simulation-based education has improved learner knowledge, skills, and ability to transfer knowledge and behavior to the practice site.

As with all research, it is important to use tools with established validity and reliability and ensure good rater training. Fey, Gloe, and Mariani (2015) published a helpful rubric for assessing simulation-research articles. In addition, the 2016 International Nursing Association for Clinical Simulation and Learning (INACSL) Standards for Best Practice: SimulationSM provides evidence-based standards for developing, facilitating, and measuring the effectiveness of simulation-based education (INACSL Board of Directors, n.d.). Information about the standards can be found on the INACSL website.

The Future of Simulation in Nursing

Simulation can provide students with opportunities they would not get in the clinical area. Simulation is a safe way for students to learn: they can practice until they achieve skill competency; and they learn how to reflect upon what went wrong; how to self-correct; and how to accept feedback. Clinical sites are often scarce and students may only ‘shadow’ another person; these clinical learning experiences can be less than optimal. Simulation can provide students with opportunities they would not get in the clinical area.

However, simulation is a different way to facilitate learning. It is not clinical teaching and it is not classroom teaching. To do it well, faculty need to learn to effectively design, facilitate, and debrief simulation-based experiences to meet objectives for learning experiences. Use of virtual simulations needs to become part of the overall simulation program. Although virtual and augmented reality are still in early stages, this option will grow quickly now that the technology is becoming available and affordable. Quality of devices will provide opportunities to train students in skills that required physical trainers in the past, thus opening new opportunities for schools to re-allocate space resources.

Simulation has become a large part of the undergraduate curriculum. It has grown from something that happens in the simulation laboratory by a few faculty who enjoy ‘playing around’ with technology to an evidence-based, effective learning technology. Use of simulation offers a safe space where students can learn skills they need to be comfortable and competent before entering the clinical site. Although simulation requires a significant financial investment to purchase simulators and provide dedicated space and personnel, there are many advantages to incorporating more simulation into the UG curriculum.

Author

Michelle Aebersold, PhD, RN, CHSE, FAAN
Email: mabersol@umich.edu

Michelle Aebersold, a Certified Healthcare Simulation Educator, is a Clinical Associate Professor and Director for Simulation and Educational Innovation at the University of Michigan School of Nursing (Ann Arbor, MI). Previously she served as Nurse Manager for the Neuro Intensive Care Unit, Neuro Acute Care Area, and the Stroke Unit at Michigan Medicine. Her scholarship is focused on advancing the science of learning as applied in simulation, with the goal of aligning clinician and student nursing practice behaviors with research evidence to improve health outcomes of populations. Her interest in healthcare simulation arose both from her love of video games and from her knowledge about how simulations in other educational areas can help people learn. She publishes extensively, most prominently in the area of virtual simulation. She is also actively involved in the development of simulation standards and in guiding future research efforts related to simulation-based learning.

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© 2018 OJIN: The Online Journal of Issues in Nursing
Article published April 4, 2018


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