As the use of high fidelity simulation (HFS) in nursing education increases, evidence of its impact on learner self-confidence continues to grow. However, evidence to demonstrate an actual, positive influence on learner competence remains inconsistent. This lack of clear evidence supporting increased clinical competence challenges faculty seeking effective teaching strategies related to HFS. The purpose of this article is to discuss two key challenges in the integration and use of HFS in nursing curricula. The authors review the use of HFS in nursing education and provide a critical discussion of two challenges to incorporating HFS into the nursing curricula: the dangers of risk sensitization and the need for a standardized framework. They conclude that simulation experiences that encompass the element of longitudinal care and patient response, along with further research identifying best practices are needed to provide a sound basis for supporting the use of HFS in nursing education.
Keywords: high fidelity simulation, undergraduate nursing education, nurse competency, clinical judgment, clinical reasoning, risk, simulation design, learning outcomes, simulation design, simulation framework
Undergraduate nursing programs are looking for evidence that will support the use of HFS and guide best practices in the use of simulation to improve learner outcomes. Undergraduate nursing programs are looking for evidence that will support the use of high fidelity simulation (HFS) and guide best practices in the use of simulation to improve learner outcomes. The purpose of this article is to discuss two key challenges in the integration and use of HFS in nursing curricula. The first challenge is related to the potential for sensitizing students to risk events that may impact the learners’ overall nursing competence. The phenomenon of sensitizing students to risk is based on a common use of HFS involving simulations focusing primarily on emergency situations, thus reinforcing reactive rather than proactive (anticipatory) skill sets. Risk sensitization is problematic because it can limit students’ ability to take in and process information, for example in situations where a patient’s condition is in the very early stages of deterioration. The second challenge is the lack of a standardized approach to measuring and evaluating competence outcomes among nursing students. In this article, we will describe the use of HFS in nursing education and address the challenges of risk sensitization and the lack of a standardized approach to measuring and evaluating competence outcomes. We will recommend that simulation experiences include both acute and longitudinal care, and that educators conduct additional research to fully understand the best practices in using HFS in educational settings.
Use of High Fidelity Simulation in Nursing Education
HFS goes beyond the sophistication of basic simulators by including aspects of realism related to the physical and psychological learning environment. HFS goes beyond the sophistication of basic simulators by including aspects of realism related to the physical and psychological learning environment (Rogers, 2007). HFS seeks to address the cognitive, affective, and psychomotor domains of active learning (Bastable, 2008). For the purpose of this article, HFS is defined as a replicated clinical experience using a computer-driven, full-bodied simulator with physiologic responses to interventions. Common, computer-driven simulators used for HFS include Laerdal’s Sim Man® and METI’s iStan®. These simulations occur in a realistic context that emulates an actual clinical scenario and incorporates visual, tactile, and auditory cues. The learner is engaged in deliberate practice to meet cognitive, affective, and psychomotor objectives (Cannon-Diehl, 2009; McGaghie, Issenberg, Petrusa, & Scalese, 2010).
The integration of HFS into nursing education has increased in recent years and is now used to augment clinical practice hours. This practice of augmenting clinical practice hours with simulation is actively promoted by the American Association of Colleges of Nursing (AACN) and its associated Commission on Collegiate Nursing Education (CCNE). The AACN (2008) has noted that simulation effectively provides a safe environment for learning and applying essential skills for nursing practice. HFS is also actively promoted by the Agency for Healthcare Research and Quality (AHRQ, 2008), which has asserted that simulation allows practitioners to practice and enhance individual and team-based skills in a safe environment prior to encountering actual patients.
A major value of HFS influencing its use in nursing education is that it provides students with the opportunity to develop specific skills through deliberate practice without the risk of harm to patients (Cannon-Diehl, 2009; Decker, Sportsman, Puetz, & Billings, 2008). HFS also permits instructors to provide the students with exposure to specific clinical experiences that are not dependent on having an available patient population for student experiences (Nehring, 2008). In the clinical setting high acuity significantly limits the types of care that can be provided safely by students (Norwood, 2008). Additionally, rapid patient turnover reduces opportunities for students to perform certain tasks in order to meet specific learning objectives (Schoening, Sittner, & Todd, 2006). These uncontrollable factors can limit the breadth and depth of learning that can occur during any one clinical day, thereby undermining the potential value of the clinical experience. HFS addresses these challenges by providing the opportunity for students to practice and develop skills in a safe and controlled setting, free from the risk of harming patients, and in a way that simulated patient encounters can be predetermined in order to develop skills that meet targeted learning objectives (Cannon-Diehl, 2009; Decker et al., 2008). In summary, HFS creates the opportunity for students to gain mastery in specific skills identified as fundamental to practice in clinical specialty areas.
As nursing programs look for evidence to support and guide the use of HFS in nursing curricula, it is essential that the challenges to using HFS be critically explored and evaluated so as to promote best practices. Two significant challenges exist to incorporating HFS into nursing curricula. The first is the potential for sensitizing students to risk through a disproportionate use of HFS focusing on critical, emergency events. The second is the lack of a standardized approach to measuring and evaluating competence outcomes among nursing students. These challenges will be described below along with strategies for addressing each challenge.
Challenges to Incorporating HFS Into the Nursing Curricula
... when student nurses are exposed to predominately emergent situations, they may become sensitized to critical events... Although much of the HFS literature is based on use of HFS for high-risk, low occurrence critical events, little is known regarding the extent to which nursing programs consistently use HFS for critical events (Birkhoff & Donner, 2010; Burns & Poster, 2008; Henneman & Cunningham, 2005; Norwood, 2008; Radhakrishnan, Roche, & Cunningham, 2007; Rodgers, Securro, & Pauley, 2009; Schoening, et al., 2006). However, the manner in which HFS is currently used for high risk, low occurrence education has the potential to disproportionately expose students to emergent (emergency) clinical situations focused on reactive behaviors. In everyday practice, relatively few patient care encounters involve a critically unstable patient requiring emergency action on high-risk issues. However, when student nurses are exposed to predominately emergent situations, they may become sensitized to critical events, due to the psychological process of risk sensitization (Eiser, 2004; Kneebone, Nestel, Vincent, & Darzi, 2007). They may begin to expect the deteriorating patient to require emergency intervention during every patient encounter, since their previous experience in simulation may have primed them for such likelihood and consequences. It is possible that this approach provides little experience in the trajectory of patient care involved with non-emergent patient conditions that may or may not result in a high-risk event.
When faced with conditions of uncertainty in which a particular outcome is desired, human action is guided by prior experience. The lack of balance between reaction to crisis events and the gradual anticipation of crisis events is problematic. Reactivity can sensitize students to risk in a way that leaves them with a heightened state of awareness, which impedes their ability to take in the whole picture and process information (Eiser, 2004; Kneebone, Nestel, Vincent, & Darzi, 2007). Eiser (2004) describes risk sensitization as a characteristic of human action that involves uncertainty, benefit, and cost. When faced with conditions of uncertainty in which a particular outcome is desired, human action is guided by prior experience. According to Eiser (2004), when there is uncertainty about the outcome and a degree of risk is involved, the individual may develop a bias towards false alarms. When applied to simulation in nursing education, if the preponderance of scenarios are high-risk, rare events, then students may become risk adverse and conditioned to expect all clinical events to be critical in nature (Kneebone, et al., 2007). Combining this established expectancy with the tendency of positive patient outcomes in simulation, an illusory over-confidence in behavior can result (Eiser, 2004).
This bias and modification of expectancies, which can lead to partial and selective sampling of available information, does not always result in greater accuracy in future situations (Eiser, 2004). This can limit a student’s information-seeking behaviors and subsequently their ability to develop robust observation and assessment skills vital for quality care. The tendency for incomplete information gathering associated with risk sensitization may further limit the student’s ability to differentiate the ‘signal’ of the clinical warning signs from the ‘noise’ of other clinical distracters. For example, in the case of a patient suffering from a stroke and who fell at home, slurred speech and facial droop would be the warning signs, whereas hip pain and ecchymosis would be the distractors. The slurred speech and facial droop are the warning signs (or signal) suggestive of a stroke, and hence key indicators of the clinical priority. In contrast, however, the hip pain and ecchymosis are the distractors (the noise) because they are not related to the priority clinical problem that could result in a critical event. As such, a signal can be as obvious as a disorganized rhythm (ventricular tachycardia, the critical event) or as covert as the insidious progression that can lead to a critical event, such as the vague first signs of a heart attack in a female (jaw pain and epigastric discomfort). When the uncertainty and consequence of the outcome are misjudged, and incomplete feedback is received, false alarm expectancies are reinforced. The end result may be an unconsciously incompetent learner with high self-confidence and a sensitization to risk that increases the inclination for false alarms. The effect of perceived risk on human decision making has been clearly demonstrated in multiple disciplines (Eiser, 2004); however, it has not been previously applied to simulation design in nursing education.
Consistent exposure to a balance of different types of simulation scenarios that require both reactivity and proactivity may be a more effective means to develop learner assessment skills... Consistent exposure to a balance of different types of simulation scenarios that require both reactivity and proactivity may be a more effective means to develop learner assessment skills that aid early identification of problems. The ideal skill set for undergraduate nursing students is to learn how to apply both prevention and intervention skills necessary for safe and competent care. According to Kneebone and colleagues (2007), safe and competent care requires an awareness of the dynamic processes inherent in routine practice and the ability to recognize problems at an early stage and intervene before they escalate into an adverse event. This may be more readily achieved if the focus of HFS is proactive, vigilant, and anticipatory nursing care. While critical event training is vital when emergency response and resuscitation are the object of the simulation, the learning that is achieved in such situations does not constitute the scope of essential nursing competencies as a whole. This is not to say that teaching nursing students how to act during high-risk, rare events is not an appropriate use of simulation. Rather, it is saying that HFS can and should also be used to educate students on how to provide care that reduces the risk of patient deterioration that could result in a critical event.
Research is needed to understand if simulation designs involving brief patient care encounters of acutely deteriorating patient conditions provide learners with the opportunity needed to experience the complex cascade of observing, communicating, and responding to clinical triggers in the patient care trajectory. Further research is needed to explore the types of scenarios and simulation structures that best teach students how to effectively observe, assess, communicate, and respond appropriately to clinical triggers in order to adequately develop the skills essential for distinguishing between “signals” and “noise.” Adequately preparing students with the skills necessary to respond to a critical or emergent situation is imperative. Future research is also needed to demonstrate the most effective way to use HFS to teach students the necessary anticipatory skills to recognize the signs of impending clinical deterioration from the noise of benign clinical findings so that they can avert critical care events from occurring where possible. Furthermore, while exploring changes to simulation design, the concepts of simulation fatigue and faculty burden also need to be investigated to determine whether shorter scenarios or longer simulation immersions correlate with improved psychomotor skills and development of clinical judgment. With lengthened simulation immersions, it is important to examine the potential impact longer simulations have on faculty time and resources.
Research is also needed to understand the effect that simulation has on nursing students’ expectations regarding the reality of practice. Since the majority of simulations are based on teaching students to intervene in high-risk, low volume situations, it would be informative to know if the use of HFS improves their ability to prevent adverse events or influences their use of health care technologies. Examples of such technologies include, but are not limited to the use of point-of-care access to informational resources, barcode scanning, and tele-health resources. Increasing the body of knowledge in these areas can help provide direction to address the growing concern about, and practice implications of, risk sensitization in HFS education. Such research would ultimately help guide the development of a standardized framework to help ensure simulations are designed and integrated throughout curricula according to best practices that directly address issues pertinent to preparing competent nursing graduates, as discussed further below.
Need for a Standardized Framework to Assess Outcomes
Standardization is needed both to design effective HFS learning experiences and to measure HFS outcomes. This section will explain the need for standardized outcome measures and the value of a standardized HFS learning experience in outcome achievement.
Self-confidence and competence outcomes in simulation. Measures of self-confidence and competence among undergraduate nursing students are two major outcomes of interest throughout the simulation literature (Decker et al., 2008; Harder, 2010; McKeon, Norris, Cardell, & Britt, 2009; Sullivan, Hirst, & Cronenwett, 2009). In terms of self-confidence, the nursing literature contains a growing number of articles suggesting that simulation increases student self-confidence and perception of readiness for clinical practice (Bambini, Washburn, & Perkins, 2009; Cant & Cooper, 2010; Moule, Wilford, Sales, & Lockyer, 2008; Schoening, Sittner, & Todd, 2006; Wagner, Bear, & Sander, 2009). In addition, HFS is associated with increased satisfaction and engagement in the learning process (Jeffries & Rizzolo, 2006; Lasater, 2007; Rodgers, 2007).
Although studies consistently report increased self-confidence... findings related to demonstrated competence are inconsistent. Although studies consistently report increased self-confidence at statistically significant levels, the findings related to demonstrated competence are inconsistent (Blum, Borglund, & Parcells, 2010; Radhakrishnan et al., 2007; Rodgers et al., 2009). Many studies vary in their conceptual definition of competence; others lack a clear and consistent definition of competence. Both of these situations could account for the inconsistent findings regarding the impact of HFS on competence. Because of these inconsistencies the findings cannot be compared between studies or used to anticipate performance in clinical settings. Although varying definitions of competence exist, for the purpose of this article, competence is defined as “the acquisition of relevant knowledge, the development of psychomotor skills, and the ability to apply the knowledge and skills appropriately in a given context” (Decker et al., 2008, p.75).
Another major shortcoming in the simulation literature regarding self-confidence and competence is that most of the studies do not address the validity and reliability of evaluation tools used to measure the educational outcomes (Schaefer et al., 2011). The lack of psychometric reporting poses a significant challenge, making it difficult to interpret or generalize findings to provide evidence to develop best practices for the use of HFS.
Although Issenberg, McGaghie, Petrusa, Gordon, and Scalese (2005) and McGaghie et al. (2010) have reported that methodological rigor and the quality of quantifiable outcomes in the simulation literature has been historically weak, rigor has improved in recent years (McGaghie et al.). However, the majority of the studies about simulation used a qualitative or descriptive method with a focus on student and faculty perceptions (Bantz, Dancer, Hodson-Carlton, & Van Hove, 2007; Baxter, Akhtar-Danesh, Valaitis, Stanyon, & Sproul, 2009; Henneman & Cunningham, 2005; Kardong-Edgren, Starkweather, & Ward, 2008). More rigorous studies focusing on measurable outcomes associated with HFS are needed to advance the state of knowledge regarding simulation in nursing education.
Potential impact of HFS use and design on outcome achievement. Understanding why simulation may increase self-confidence and perception of readiness without increasing clinical competence might be partially explained by examining the ways in which simulation is currently used in nursing education. Contemporary knowledge about simulation is based on use of HFS for sentinel event training and high-risk, low-occurrence, critical events focused on unstable or deteriorating patient conditions requiring emergency response or resuscitative efforts (Birkhoff & Donner, 2010; Burns & Poster, 2008; Henneman & Cunningham, 2005; Norwood, 2008; Radhakrishnan et al., 2007; Rodgers et al., 2009; Schoening, Sittner, & Todd, 2006). The lack of a standard model to structure the use of HFS, a model that can develop strong clinical judgment and reasoning skills, makes it impossible to compare findings across studies, so as to identify best practices or develop evidenced-based models. Jeffries and Rizzolo’s (2006) study about HFS has made a significant contribution to nursing education because it provided one of the first standardized frameworks for the use of HFS. The framework proposed by Jeffries in 2007, the Nurses Education Simulation Framework (NESF), was a first attempt to provide a broad general educational model for simulation in nursing education.
...there remains a need to understand how best to use simulation to teach and assess competence... along the trajectory of a patient’s care. More recently, the International Nursing Association for Clinical Simulation and Learning (INACSL) has published seven standards of best practice in simulation. These standards address aspects of simulation ranging from establishing participant objectives to evaluating expected outcomes (INACSL, 2011). Although the INACSL does not provide a standardized framework to guide simulation, these standards represent a strong first step in identifying priority areas for future development of simulation guidelines. These simulation standards highlight the importance of having a standardized approach to the design and implementation of simulation across the entire spectrum of use.
Standardized simulation frameworks, based on best practices and purposely designed to increase competence without sensitizing learners to risk, are needed to move the discipline of nursing forward. One possible solution is a framework that addresses the need for HFS to be longer to capture nuances and deviations in health status that occur over time. By lengthening the time of the simulation immersion, it is proposed that the scenario can be designed to represent the incremental cascade of errors and omissions over time that culminates in high-risk, critical events. Longer scenarios that more closely represent the nature of clinical practice could provide an opportunity for students to learn how to anticipate and respond accordingly (Kneebone, 2007). HFS should be an immersive experience, enabling the student to actively engage in the realistic process of care that reflects daily clinical practice in regards to patient acuity, response, and progress. Standardized frameworks for this type of HFS design could also help maintain a balance across the curriculum between emergent scenarios focused on reactive behaviors and unfolding scenarios focused on proactive behaviors.
For HFS to be an effective mechanism to promote the core competencies necessary to reduce error rates, improve quality of care, and demonstrate increased competence, the models must also be testable. By ensuring testable models, additional research can explore the ability of simulation to promote sustained competence over time. Although short, competency-focused simulations can provide snapshots of performance during a moment in time, there remains a need to understand how best to use simulation to teach and assess competence in observing, communicating, and responding to clinical triggers along the trajectory of a patient’s care.
The current body of knowledge addressing the effects of HFS in nursing education reports increased self-confidence and mixed findings on the effectiveness of developing clinical competence.For nursing students to learn skills necessary to observe, communicate, and respond to clinical triggers along the trajectory of patient care, it is proposed that simulation should encompass elements of longitudinal care and patient response. However, the current use of HFS as reported in the literature remains predominately focused on brief patient encounters involving deteriorating patients that require emergent care. This emergent care focus may account for the lack of consistent evidence on the effectiveness of simulation to develop clinical competence in nursing students due to the risk sensitization that can potentially occur. For nursing students to learn skills necessary to observe, communicate, and respond to clinical triggers along the trajectory of patient care, it is proposed that simulation should encompass elements of longitudinal care and patient response. This more balanced focus would provide an opportunity for students to apply and develop the skills necessary to cultivate both anticipatory and reactionary responses.
To address challenges of possible risk sensitization and inconsistent outcome measurement in HFS, more research is needed to understand the best practices of simulation to achieve desired outcomes, especially since little evidence exists to identify the most effective simulation design (Schiavenato, 2009). Additional research is needed regarding the most effective way to structure HFS to develop strong psychomotor and cognitive judgment skills in learners while addressing the challenges inherent in HFS design, implementation, and evaluation.
This further research can support a sound basis for building the scientific evidence necessary to shape and support the use of HFS in nursing education, with careful consideration to risk sensitization and outcome measurement. With best practices of HFS in place, learner competence can be consistently established, evaluated, and improved in both academic and practice settings, ultimately improving patient care quality and outcomes.
Rachel Onello, MS, RN, CNL
Rachel Onello has taught in simulation-based courses and labs for four years where she designs, implements, and evaluates simulation instruction. She served as the Assistant Director of the Clinical Simulation Labs at the University of Maryland School of Nursing in Baltimore, MD for almost two years where she collaborated with faculty and clinical-based educators on the design and integration of simulation into program curricula across health disciplines. Ms. Onello currently serves as a faculty member at the University of Maryland School of Nursing, coordinating the simulation-based instruction and testing of first semester entry level nursing students. She also serves as an adult specialty faculty member for entry level nursing students in their final practicum clinical course. She is pursuing her PhD in nursing with a focus on the use of simulation as a modality for the faculty development of clinical instructors.
Mary Regan, PhD, RN
Mary Regan has over 20 years of clinical experience in perinatal nursing in the United Kingdom and Canada. While pursuing her master’s degree, she became interested in the use of high fidelity simulation in undergraduate nursing education. Dr. Regan completed a PhD and National Library of Medicine post-doctoral fellowship at the University of Minnesota in Minneapolis, MN with a focus on health informatics; she currently works in the informatics program at the University of Maryland School of Nursing. She has a federally funded program of research rooted in behavioral informatics. Currently, her research focus is on the use of technologies on health outcomes. She has also conducted several studies about simulation and its effect on clinical reasoning in undergraduate nursing education.
© 2013 OJIN: The Online Journal of Issues in Nursing
Article published July 11, 2013
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