Download the full paper here: Diversifying Nursing Education through Sims
Nursing is a complex field which requires numerous skills be developed in addition to learned base knowledge. Nursing skills, such as medication administration and patient assessments, can be challenging tasks for students to learn through traditional classroom lecture style teaching. Procedural steps can be taught this way, but there is a level of muscle memory that needs to be developed. Working with patients in a clinical setting certainly provides an opportunity for students to build up their hands-on experience, however it does come with some risk to the patients when the students are performing a task for the first time. Simulations provide a controlled learning environment for students to be able to practice these applied skills under observation by an instructor without direct patient contact, which can increase patient safety if mistakes are made, or the student is unsure about the order of steps they should take.
Simulations can take place in a variety of settings using various methods. The traditional setting is in a simulation laboratory where the students work with a mannequin to run scenarios as if they were providing direct patient care. A less common setting would be to bring the simulation into the classroom setting, in lieu of a traditional lecture or case study. A third method, which has been rising in popularity since 2019 due to restrictions set on in-person interactions due to the COVID-19 pandemic consists of online learning in the form of virtual simulations. All these methods of simulating patient care can be beneficial to nursing students learning skills if they are used effectively.
Simulation Labs
Simulations are traditionally performed in a laboratory setting designed to replicate a real clinical setting, such as a patient’s room in a hospital. They often include a mannequin to represent the patient, monitors for checking vital signs, and sometimes incorporate actors such as faculty, fellow students, or volunteers to play additional roles as family members or other health care providers. This setting allows students to practice their clinical skills in a safe and repeatable setting.
Simulation labs can be a valuable learning tool for nursing education by keeping the stakes low so students can learn and practice skills. Sears et al. (2010) used simulations in a lab setting to replace some of the early clinical experiences for their nursing students, giving them time to practice assessments and medication administration in a safe environment before moving into a clinical setting with real patients. This allowed time for the students to practice their skills, ask questions, make mistakes, and get feedback from their instructors before working with patients where errors could be harmful. The study showed that giving students time in this setting before administering medications to real patients reduced the number of errors made, which increased patient safety in the clinical setting (Sears et al., 2010). Since nursing is a skills heavy profession, it is important that students have time to practice skills hands-on, and in an environment where there is minimal risk potential, such as working with a mannequin in a simulation lab, to increase their knowledge and confidence for a particular skill. The repeatable nature of using a mannequin also allows more students time for that hands-on practice with their instructor’s assistance. In the clinical setting, instructors often bounce among students to watch or assist with skills, whereas in the laboratory setting they can rotate the students through the scenario and give equal amounts of time and feedback to each of them.
Another benefit to simulations is the ability to create atypical scenarios, such as critical events, or for nursing specialties that are harder to get clinical placements for, such as pediatrics. Simulation labs are often used to demonstrate to nursing students how they should respond in emergencies because they might not get a chance to assist in these events in the clinical setting due to their unplanned nature. In addition to critical events, Lewis and Ciak (2011) point out that simulations can be beneficial in giving students time to practice skills in settings that can be difficult to get clinical placements in. Specialty nursing departments often have a limited number of spots open for taking students, which can impact the learning of a nursing class. Using simulations to teach these specialty areas, such as obstetrics, can help to restore the balance of nursing students with some experience in these areas. This provides for more equitable training for all of the nursing students in a class. Lewis and Ciak (2011) focused their simulations on pediatrics and obstetrics with the goals of increasing student knowledge, satisfaction, critical thinking, and confidence. Despite finding that critical thinking was hard to assess in the students, they found positive results from the simulations in the other three areas. This shows that simulations can be a beneficial learning method for nursing students in learning these specialties. Pediatrics and obstetrics are both areas that many nursing students are interested in, so allowing time for them to have experience, even if it isn’t in direct patient care, can help to foster learning necessary specialized skills.
Simulation in Classrooms
Although some parts of nursing education are still best taught via lectures, simulations can also be useful in the traditional classroom setting. This method of simulation is less common; however, it can still have educational benefits for nursing students to grasp difficult concepts.
Beyer (2012) brought a human patient simulator into a lecture classroom with forty-five nursing students in order to use it as a hands-on version of a case study. While this only provided bedside practice to six of the students, the others were able to watch and participate as the case unfolded. Each of the students were provided with the same background information and could make suggestions or ask questions as they arose, which allowed for hands-on learning for all of them. Pre- and post-tests were given, and the improvement in results showed a significant increase in student learning through the simulation activity (Beyer, 2012). This study demonstrated the flexibility of simulations as a tool that can be carried over into the theory part of nursing education, as well as traditional labs. With a little creativity on the educator’s behalf, simulations can be altered to fit in a variety of settings. Using a mannequin to walk through a case study provides students with a more realistic idea of how scenarios run in real time, allowing for immediate feedback to interventions, and practice of their nursing skills. This is also an effective way to break up long lecture periods to keep students engaged, allowing time for movement and critical thinking, in addition to taking notes and processing information.
Another method that can incorporate simulation into the classroom setting is having students role play with each other, rather than using a mannequin as the patient. Scenarios are still given to the students, and they are able to work with each other to problem solve and provide suggestions. Goldenberg et al. (2005) used this method with nursing students to practice teaching health education concepts to each other. Role playing can feel more relaxed to students than a traditional simulation lab, which decreases anxiety about the activity and can have positive benefits on learning. Goldenberg et al. (2005) also noted that students found the characters within the simulation experience to be relatable, likely due to the teacher’s pulling examples from real-life and common situations that students face in clinicals. By making the simulations as realistic as possible, students can build on experience and their knowledge gained in traditional lecture classes. Learning activities should build on each other to increase student’s skills and confidence and ultimately prepare them for their independent practice. Working simulation activities into the classroom setting, educators encourage nursing students to retain the information better by providing examples and allow time for practicing skills that are discussed in the lectures.
Virtual Simulations
With the increased emphasis on technology in younger generations, as well as the impact from the COVID-19 pandemic shutting down a lot of in-person learning environments, there has been an increase in online learning. With the nature and purpose of simulations providing critical hands-on learning, the question could be asked, how do simulations fit in with an online learning model? One answer to this has been the increased use of virtual simulations, which are learning experiences where the students have the opportunity to watch and interact with a patient scenario via a computer-based program.
Virtual simulations can have benefits for students who are accustomed to using technology in their learning. Padilha et al. (2018) had their nursing students participate in a virtual simulation experience in-person using a touchscreen table with web applications. They found that their nursing students were motivated to use virtual simulations and gave the tools positive marks for ease and usefulness, while also seeing an increase in critical thinking abilities. This method of teaching gave students a big picture view of the patient scenario, allowing them to interact with it to demonstrate nursing skills without using a mannequin or real patient. The online environment allowed students to choose which actions they wanted to take, work together with classmates, and receive feedback from the instructor. A concern that may arise with the implementation of online learning tools, such as virtual simulators, is the accessibility of the tool. To control the experience, Padilha et al. (2018) required the students be present for the activity, rather than relying on each individual student to have a computer with internet access. They also took into account students’ unfamiliarity with the program by allowing for a briefing time and demonstration at the start of the simulation experience so that students would understand how to use the tools. This brings up an important point for educators who want to use novel teaching methods, such as virtual simulations, that proper instruction for the students of the expectations and how to use the tool is important for an effective learning session.
Virtual simulations can also be useful for distance learning, such as what the COVID-19 pandemic led to for many nursing schools. Cooper et al. (2017) used an online virtual simulation program which is accessed through the internet and was completed individually. The virtual simulation in this study had a pre- and post-test to assess student learning, with three virtual simulation interactive videos in between. Students accessed the content on a computer with internet access and completed the activities by clicking on the actions they want to take, allowing them to still make nursing decisions and apply critical thinking. A benefit to this method of virtual simulation is that students are able to complete the activities from their preferred learning environment. A downside to this style of simulation is the lack of personal interaction with others, either their fellow classmates, instructors, or patients. Cooper et al. (2017) did find a statistically significant increase in the post-test scores following the learning activity, which suggests that learning did occur for students despite the lack of interaction. When in-person practice is not an option, other venues must be utilized by educators, and having a virtual patient scenario learning experience can be a helpful tool to keep in mind. This experience could be built upon by the educator to be made even more effective by gathering with the students to do briefing and debriefing sessions, allowing for time to give instructions, state expectations, answer questions and give feedback. This could be done in-person as the program allows, or via a virtual gathering such as Zoom meeting in a fully online learning environment.
Virtual simulations do pose a different set of challenges than other types of simulation environments, and educators leading them should be prepared for issues that might arise. They should be cognizant to students with limited access to or knowledge of how to use computers and be able to provide resources to those who need them. As with any technology used for education, there is also always the looming possibility of information technology (IT) issues arising. Educators who want to use these tools should have a working concept of troubleshooting methods and contact information for someone who can help to resolve IT issues that arise.
Conclusion
Simulation experiences can have tremendous benefits for nursing students’ learning and developing their procedural nursing skills such as medication administration. Simulations actively engage learners in processes, while allowing a safe space for mistakes, feedback, and note taking, which often can’t be achieved through other learning methods. Simulations should be directed by faculty to ensure learning objectives are met, questions are answered, and mistakes are corrected. As the educational environment rapidly changes to meet students’ needs, so should the implementation of simulation. The research shows that simulations are effective in traditional laboratory settings, the classroom setting, and even virtually. Educators should be flexible in teaching styles in order to engage their students’ attention and ensure effective learning in any setting. Simulations should also be used to build upon skills taught in classroom settings, helping nursing students visualize the order of steps to be taken or problem solve their way through complex scenarios. Appropriate use of simulations can increase confidence in these students and help prepare them for their own practice as nurses.
Postscript
While the research shows that simulations are a great educational tool for nursing students, as one who went through nursing school recently, I have some opinions which disagree. I found simulation days to be stressful, especially at the beginning of my program, as I knew my classmates were watching my performance from the simulation control room and I was unsure of my skills. I felt that the additional eyes on me put extra pressure on me to do everything correctly despite the fact that it was a learning process, and my teacher didn’t expect me to know everything. I think it is important for educators to emphasize that the sessions are practice to help students get better, and not a comparison between the group members.
I also had the unique experience of attending nursing school when the COVID-19 pandemic hit. This forced my school to become completely online for my third quarter, including our clinical rotations which became entirely online simulations. Perhaps it was due to the unplanned transition, but I felt that the virtual simulations did not prepare me for being a nurse. My clinical group would meet on zoom for a short briefing session about the activity, briefly discussing the scenario we would complete, then we would have time to independently complete the online simulation before returning to a group Zoom meeting for a debriefing session on the scenario and what we learned. The simulations we used were interactive videos, where we got scored based on which nursing actions we took, and if they were completed in the correct order. With so many different action buttons available to us, it was a frustrating game of trying to find the action button you wanted and getting prerecorded dialog to give more information when applicable. In some scenarios, the patient would decline rapidly, and the simulation would cut off while I was digging through the multiple menus trying to find the intervention I knew I should take to treat their condition. Doing the same types of simulations week after week eventually felt redundant and unhelpful. It was an entire quarter with no opportunity to practice any skills hands-on, and when we were able to return to a clinical setting the next year left me feeling uncertain and unprepared. I understand the situation I was placed in during nursing school was not intended, but spurred on by the global pandemic, however, it made me realize the importance of actual patient interaction. Based on my own reflections on the virtual simulations I went through, I have a strong desire to avoid using them, when possible, in my future career as an educator. Perhaps virtual simulations have a place as a supplemental teaching tool, but I would caution against using them as the only clinical teaching method.
References
Beyer, D. A. (2012). Effectiveness of human patient simulator as a classroom teaching strategy. Clinical Simulation in Nursing, 8(7), e301-e305. https://doi.org/10.1016/j.ecns.2011.01.005.
Cooper, S. J., Hopmans, R., Cant, R. P., Bogossian, F., Giannis, A., & King, R. (2017). Deteriorating patients: Global reach and impact of an E-simulation program. Clinical Simulation in Nursing, 13, 562-572. https://dx.doi.org/10.1016/j.ecns.2017.06.004
Goldenberg, D., Andrusyszyn M. A., & Iwasiw, C. (2005). The effect of classroom simulation on nursing students’ self-efficacy related to health teaching. Journal of Nursing Education, 44(7), 310-314. Doi 10.3928/01484834-20050701-04
Lewis, D. Y. & Ciak, A. D. (2011). The impact of a simulation lab experience for nursing students. Nursing Education Perspectives, 32(4). https://link-gale-com.offcampus.lib.washington.edu/apps/doc/A265289782/AONE?u=wash_main&sid=bookmark-AONE&xid=39579306
Padilha, J. M., Machado, P. P., Ribeiro, A. L., & Ramos, J. L. (2018). Clinical virtual simulation in nursing education. Clinical Simulation in Nursing, 15, 13-18. https://doi.org/10.1016/j.ecns.2017.09.005
Sears, K., Goldsworthy, S., & Goodman, W. M. (2010). The relationship between simulation in nursing education and medication safety. Journal of Nursing Education, 49(1). doi:10.3928/01484834-20090918-12