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Study to assess effectiveness of simulation in undergraduate nursing education


The National Simulation Study explores the effectiveness of simulation and is expected to help determine to what degree simulation can effectively substitute for traditional clinical experience.

This study’s breadth sets it apart from previous research in which simulation was used in only a few courses or a single course. “Simulation is substituted for part of clinical experience in every core clinical course,” said Jennifer Hayden, RN, MSN, project director for NSS and research associate at NCSBN. “It is integrated throughout the curriculum.”

Using simulation technology, students are presented with medical scenarios that allow them to make decisions and then see the results of those decisions. These students will be regularly assessed for their knowledge retention and clinical judgment.

Filling a need

A national survey conducted by NSS last year found that 87% of responding nursing schools use medium- or high-fidelity simulation. Fidelity refers to the degree a simulator replicates reality. In high-fidelity simulation, the patient-care scenario uses a full-body patient simulator that can be programmed to respond to affective and psychomotor changes, such as breathing chest action. Examples of high-fidelity manikins include SimMan, METIman, and Noelle with Newborn Hal. Medium-fidelity simulations use a full-body simulator with installed human qualities such as breath sounds, but without chest rise. An example of a medium-fidelity manikin is VitalSim.

Schools have been struggling to find clinical placements for students. “You might have 15 or 16 schools of nursing in an area, so all are trying to find clinical placements for their students,” said Pam Anthony, RN, MSN, virtual hospital coordinator at Metropolitan Community College-Penn Valley in Kansas City, Mo., which is participating in NSS. “You also need master’s prepared nurses for oversight, and that’s difficult with faculty shortages.”

Clinical sites are drying up, according to Suzan Kardong-Edgren, RN, PhD, assistant professor in Washington State University’s College of Nursing in Spokane, and a member of the NCSBN national study team. “There are only a few places in the U.S. where students get to do much more than observe in pediatric areas because the margin of error is very slim. Hospitals don’t want the liability.”

Students are more welcome on med/surg units, but Kardong-Edgren said patient acuity and the number of students faculty are expected to supervise make it difficult to provide effective clinical experiences. “You can’t guarantee the kind of experience students will have in the hospital,” Anthony said. “Their patients might be discharged at noon or at a procedure all day.”

In simulation, students can make decisions and make mistakes. “Simulation takes what otherwise would be an observational experience and translates it into a safe environment where the student can play the role of the nurse in every way,” said Henry Henao, ARNP, MSN, FNP-BC, director of the Simulation Teaching and Research Center and clinical assistant professor of nursing at Florida International University in Miami. With simulation, students can communicate with other “providers” and see the effect their decisions have on the “patient.”

One resource for faculty to learn how to best use simulation as a teaching tool is the National League of Nursing’s Simulation Innovation Resource Center, supported by Laerdal Medical. “It has a variety of resources,” said Mary Anne Rizzolo, RN, EdD, ANEF, FAAN, an NLN consultant who is working on the center. “The main piece is a series of online courses for faculty on how to design, develop and integrate simulation into the curriculum.”

Two additional resources are the Society for Simulation in Healthcare, which focuses on improving simulation and accredits programs, and the International Nursing Association for Clinical Simulation and Learning, which has developed standards of best practice.

Competition and commitment

The study application asked about the nursing program’s commitment to the project. “It takes a village at each school to be able to do the study well,” said Hayden. That includes two teams: the study team, which manages the operational details, and the oversight team, which ensures the integrity of the study is being maintained. Study team leaders dedicate half their workload to the study, and other participating faculty dedicate anywhere from 14% to 90% of their time. NCSBN provides salary funding commensurate with the time used.

Once the schools were selected, faculty attended three education sessions before enrolling students, where they learned how to conduct simulation in a consistent way and how to use the evaluation tools. To further ensure consistency, each school chooses simulation scenarios from a list provided by NSCBN.

Schools held recruitment sessions to explain the study to the students, who then signed a consent form if they chose to participate, Henao said. “We talked about the importance of the research and how their participation would help determine what nursing education looks like in the future,” he said.

Not surprisingly, students wanted to know if participating would mean more work for them. “We let them know that their requirement to do 90 hours of clinical in a course doesn’t change, the only change is where they do some of that work,” Henao said.

Anthony said students enrolled at Metropolitan Community College-Penn Valley were shown examples of upper-class students performing simulation, and a PowerPoint presentation and video from NCSBN were also screened. “We talked a lot about the ongoing evaluations and how valuable that would be for them, especially because they will get more feedback earlier in the program,” Anthony said. And students don’t have to pay the normal fee to cover the cost of standardized testing.

Testing, testing …

Evaluations focus on clinical competency, nursing knowledge, and how well students’ learning needs are met in the clinical versus simulation environments. Instructors will use the Creighton Competency Evaluation Instrument throughout each course, and the NCSBN will provide safety data reports, with benchmarking against national results, every two weeks.

“We can’t allow the study to hinder a student’s performance,” Hayden said. “The instructors are the first line of defense against that and the oversight team is the second line of defense.” Students who are not doing well will receive the assistance they normally would in a traditional program, she said.

At the end of each clinical course, students will complete standardized knowledge assessment tests from ATI, and surveys on how well they felt their learning needs were met. At the end of the first and second years of the study, evaluators will rate students using the Quint Leveled Clinical Competency Rubric, a more detailed report than the CCEI. Schools will use appraisers other than undergraduate instructors, such as graduate faculty or graduate students, to conduct the evaluations to prevent biased results.

The NCSBN study team is still working on how nurses will be evaluated after one year in practice.

Students can choose to exit the study at any time, so faculty and researchers need to identify potential problems early. Anthony said a website allows students to connect with students at other sites.

Results from the study likely will affect how often nursing programs use simulation. “I feel I’m getting the opportunity to be a part of major change in philosophy in nursing education,” Anthony said.

“We know a lot of people are waiting to hear what comes from it and we understand the potential scope of the study’s influence on nursing education,” Henao said. “We take that very seriously and aim to do a good job.”

Kardong-Edgren said simulation continues to evolve. “We’re looking at simulation as theater,” she said. Many schools have hired cinematographers or those with theater and tech experience to run the scenarios, working collaboratively with those who have medical backgrounds. The instructor then runs the debriefing. Manikins with bells and whistles may be less important when simulation is seen as theater. “It can be very effective without having to spend a lot of money,” she said.

Other trends include using mobile vans that travel to schools and hospitals in rural areas to offer simulation training, and more interprofessionally run simulation centers. “Simulation is not going away,” Kardong-Edgren said. “It’s here to stay.”

Cynthia Saver, RN, MS, is president of CLS Development Inc., Columbia, Md.


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