Designing effective, innovative training methods that consolidate nurses’ learning and facilitates the transition from theory to practice is not only important to meet standards of regularity bodies, but also to assess and strengthen the skills and competences of employees to enhance the overall knowledge and practice of the nursing profession.
Nursing education is being challenged by the lack of clinical experiences to develop nurse’s clinical and non-clinical skills and competence and preparing them for real practice. There is much literature to suggest variations exist in clinical opportunities, which could be having a detrimental effect on the competence of both graduate and post-graduate nurses. Increasing dependency of ward-based patients require nurses to develop skills and competence in recognition and management of the ‘critically-ill-patient’.
Nurse educators are also being challenged by nurse managers and nursing-directors within practice, to develop and implement competency-based staff development and orientation programmes. In a report from the Department of Health (DoH), ‘Comprehensive Critical Care’ (DoH, 2000), its recommended interprofessional training packages be designed which enhance core skills and competences in caring for the critically ill patient. However, the National Confidential Enquiry into Patient Outcome and Death (NCEPOD), The report recommends the education of nursing and medical staff to identify patient deterioration and make informed, confident and concerned actions. More recently the ‘Clinical Indicators for Critical Care Outreach Services’ report from the Critical Care Stakeholders Forum and National Outreach Forum (2007) state it should be mandatory to provide educational programmes in the detection and response to acute clinical illness.
Over the past decade, simulation has been gaining popularity in nurse education within the UK
Due to the limitations of financial cost to setup & maintain the equipment, space, faculty time & resources of simulation training there’s an increasing need to validate the effectiveness of this method of training over traditional teaching methods
Medical based research articles that addressed the research questions however proved useful as supporting information and were comparable with the nursing studies reviewed. Some of the research was carried out by manufacturers of human patient simulators, and it was recognised this might produce a certain amount of bias. This was overcome by ensuring not all articles reviewed were sponsored by a company and they were compared with similar studies were possible. 8 research studies were finally chosen for critical review ~ UK, North America and Australia
Nurse educators are challenged to deliver competency-based training, orientation programmes and ongoing staff development. Simulation training is becoming a more popular teaching strategy in nurse education, replacing or supplementing more traditional methods. The question of whether simulation is an appropriate and effective teaching strategy to be used in nurse education were addressed using three key papers.
Results of the study indicate the students’ in the experimental group generally obtained higher marks than those in the control group ( p <0.001). Researchers conclude that simulation is beneficial in nursing education if used appropriately where students themselves should decide on the appropriate treatment and actions to care for a simulated patient, allowing them to learn from mistakes and act on their own judgement.
For the test scenario, a checklist was developed by a panel of expert nurses, containing essential actions that the novice graduate nurse might reasonable be expected to perform. They piloted the checklist with several graduate nurses from a previous cohort and subsequently refined the checklist.
Results of the study demonstrated the simulation group performed better (p<0.0001) and found no significant benefit providing didactic classroom education in addition to a self-directed learning package as students who only received the learning package performed similar to those who participated in the PowerPoint sessions. They concluded that simulation could play a key role in allowing students to develop their clinical reasoning and decision-making skills within a safe learning environment and educational activities involving simulation are more effective than traditional teaching methods
Novice nurses’ often lack confidence, and with that competence, to provide safe and effective care (Schoening et al, 2006). Studies by Bremner et al, (2006) and Schoening et al, (2006) will be reviewed to examine student’s experiences of simulation training and to answer the research question. Both researchers have used quantitative and qualitative research to obtain data for the studies. This triangulation study design allows multiple methods of data collection that enriches the perspectives of the researchers
Student comments were reviewed for general themes using qualitative analyse. Identified themes were: teaching/ learning utility; realism; limitations; confidence/ comfort
Schoening et al, (2006) developed a preterm labour simulation; chosen as the focus of the pilot simulation as such high-risk patients are rarely cared for by students without close observation (Schoening et al, (2006). The simulation was divided into two sessions. Students in groups of 7-8 were randomly assigned to roles of nurse or observer and reversed roles for the second session. The simulation was videotaped so observers could watch their peers to evaluate their performance. A debrief session allowed the group to review their findings and discuss the plan of care. Review of the videotape clarified positive and negative feedback from the group to assist with the evaluative data gathering.
Schoening et al (2006) apply content analysis procedures to analyse narrative data, to identify and cluster themes Identified themes were: skills, hands-on learning and practice; confidence, self-efficacy and non-threatening environment; critical thinking, realism, knowledge, review and decision-making.
Both researchers conclude the quantitative data indicated students increased confidence in the clinical setting following the SCE. Students reported they felt more confident when to call the doctor and that observation of other’s was useful in deciding how they would handle it differently. This research indicates that the benefits of using simulation in team working training and the importance in developing interprofessional communication. Analysis of the qualitative data by Schoening et al, (2006) suggests the increased confidence was a result of the hands-on practice, communication, teamwork and decision-making. In contrast Alinier et al’ (2005) mentions there was no correlation between confidence and level of performance whether students’ received simulation training or not.
With the increasing emphasis on patient safety and improving the quality of delivery in care, there needs to be an increase in collaboration between the medical and nursing profession. Effective application of technical skills depends on robust non-technical skills; team building and leadership, communication, situation awareness, task management and decision-making (Eich et al, 2007). Three research studies will be reviewed to address the question of whether simulation-based training can improve clinical team performance.
Ker et al, (2003) state the purpose of their study to describe the clinically based interprofessional learning they introduced and to identify themes for future evaluations using a qualitative analytical approach. A combination of structured and semi-structured observation methods were used in their data collection, utilising a OSCE checklist with agreed assessment criteria to record independent variables of collaborative teamworking, effective leadership, prioritising workload and competence in clinical performance.
Using qualitative methodology, six observers individually coded comments to identify themes. Themes identified were: educational environment, organisational issues, interprofessional aspects and communication.
Shapiro et al, (2004) use a small sample size ( n = 20) but randomly selected them from a larger convenience sample ( n = 152). The researchers prospectively followed the four teams in their normal ED rotations. Some staff schedules were manipulated to create the four teams, but the participants were unaware. An observer blinded to the identity of the group undertook observations, which reduce bias entering the results, and prevent reactivity of the participants because of the concealment without intervention observers’ role
Convenience sample ( n = 138) teams of critical care nurses, physician & respiratory therapists took part in three out of five simulated crisis scenarios Participants did not play the same role twice, avoiding improvement due to rehearsal of the same role over and over again. Scenario outcome measures were set to determine the successful crisis management. Secondary outcomes measured crisis task completion rate (TCR), which was a set of 29 tasks defined for each scenario by consensus of the course authors.
Teams who work together should train together, simulation offers the opportunity to develop the entire workforce by inviting participants to work collaboratively for effective multidisciplinary team working.
During the literature review the NMC completed their investigation, ‘Simulation and Practice Learning Project for Pre-Registration Nursing Programmes’ (NMC, 2006), which piloted simulation training at thirteen universities across the UK. Final decisions from the NMC on the report from all thirteen pilot sites resulted with the NMC agreeing to a small percentage of pre-registration practice hours in the UK being replaced by scenario based simulation training. 300 out of 2300 hours Used within an educational framework simulation training could reduce the theory-practice gap (Shepherd et al, (2007) and become an integral part of both nursing and medical curricula (Ker et al, (2003).
When considering the implications for nursing education, according to Shepherd et al (2007) simulation is only beneficial and effective in nursing if used appropriately by educators and combined with a relevant educational framework, which can be integrated into the curricula. There should be well articulated learner outcomes with clear connection to course/ clinical objectives (DeVita et al (2005); Bremner et al, (2006). These objectives can be used to guide the students’ learning and outcome achievements (Jefferies (2005). The planning, implementing and evaluating of simulation training should be done in collaboration with the student (Bremner et al, (2006).
Facilitators need to be adequately prepared to provide simulation training with clear guidelines on designing, developing, running and evaluating simulation (Alinier et al, (2006); Shepherd et al, (2007). These conclusions raise the question of the educators’ role and how simulation design can contribute to the overall teaching and learning experience. The educators’ role is considered the most important factor to ensure effective simulation-based education (Jefferies, 2005; Issenberg, 2006). The educators’ role needs to combine elements of explaining, refereeing, coaching and discussing (Schoening et al, (2006). Alinier et al (2006) suggest facilitators need to have minimal interaction with the students during scenarios to facilitate critical thinking and decision-making, allowing students to learn from their mistakes.
All researchers used a convenience sample, this type of sample is not always representative of the identified population and generalisations can only be made to populations which share the characteristics of the sample (Bell, 2006). Larger samples needs to be considered for future research. When considering future research the use of video recording, structured observation and using paired observers could provide inter-rater reliability of the results, and enables consequent checking of the consistency of verbal and non-verbal behaviour (Shepherd et al, (2007); Bryans and McIntosh (2000). This would reduce subjectivity and bias entering the results. However video recording also face significant ethical hurdles (Shapiro et al, (2004).
Schoening et al, (2007) discusses future research needs to measure knowledge outcomes, increased self-efficacy, skill mastery, and transferability to clinical practice, using reliable, valid data collection tools which compares simulation to traditional methods. Observations carried out in real practice could compare how participants function in the real world (Mole and McLafferty (2003). More robust studies, which are multi-site experimental pre-test post test design, need to be carried out that addresses the unanswered questions of whether simulation training has an impact on actual care (Shapiro et al, (2004); DeVita et al, (2005). Further research also needs to explore the ideal frequency and mode of training for refresher courses and whether learning and retention is improved.
However, using simulation as a teaching method is complex, multifaceted and challenging. Facilitators’ need to be appropriately trained and have adequate resources to design, develop and plan simulation training. Further research studies should focus on measuring the impact simulation training has on clinical practice and patient outcomes to validate its use. Nursing education and practice must embrace the use of simulation training and support its use in order to continue to advance.
In conclusion the evidence supports the use of simulation in nursing education to be an effective teaching strategy to assess and strengthen the skills and competences in nursing practice. Simulated clinical scenarios provide a realistic safe learning environment that more closely represents clinical care, beneficial to both graduate and undergraduate nurses in the transition from theory-to-practice. improve team performance managing the ‘at-risk’ patient with the potential to improve patient outcome and reduce medical errors. In comparison with traditional teaching methods, simulation appears to be more effective in developing and refining clinical skills along with non-technical skills such as communication, clinical reasoning, decision-making and interprofessional teamwork training. Used within an educational framework with learning objectives relating to clinical objectives, simulation can become integral to nursing curricula and continual professional development of nurses.
Determining the Value of Simulation Training Within Nurse Education: A Literature Review Sarah Sibley RN Senior Nurse Educator BMSC
The aim of this literature review was to determine whether simulation training is an appropriate and affective teaching method to be used in nursing. The advantages and disadvantages of simulation were explored using three sub-questions:
Is simulation based training more effective than traditional teaching strategies used in nurse education?
Can simulated clinical experiences improve confidence and competence in nursing students and prepare them for real practice?
Can simulated-training improve interprofessional team performance and improve patient safety?
Some research was carried out by manufacturers of human patient simulators
Critical Review Q1. Is simulation based training more effective than traditional teaching strategies in nurse education?
Three quantitative research papers;
Jefferies et al, (2003)
Alinier et al (2006)
Shepherd et al (2007)
Alinier, G., Hunt, B., Gordon, R. & Harwood, C. (2006) Effectiveness of intermediate-fidelity simulation training technology in undergraduate nursing education. Journal of Advanced Nursing, 54(3), 350-369.
Quantitative UK study
Aimed at determining the effect of simulation training on nursing students’ clinical skills and competence
Volunteer undergraduate students (n=99) were randomly allocated to either a control group or experimental,
A pre-test/ post-test design was used using a 15 station Objective Structured Clinical Examination (OSCE).
Experimental group exposed to simulation training as well as following their normal curriculum.
Compared the effectiveness of an interactive, multimedia CD-ROM with traditional methods of teaching the skill of performing a 12 lead ECG.
Randomised pre/ post-test experimental design to compare the two teaching methods, with a convenience sample of senior baccalaureate nursing students (n=77).
Traditional method included a self-study module, a brief lecture & demonstration by instructor and hands-on experience using a manikin and a real 12-lead ECG machine.
The simulation method covered the same content using an interactive CD-ROM embedded with virtual reality technology and supplemented by the self-study module.
Objective observation measured the students ability to perform an ECG comparing the effectiveness of the two teaching methods.
Jefferies, P. R., Woolf, S. & Linde, B. (2003) Technology-based vs. Traditional Instruction: A Comparison of Two Methods for Teaching the Skill of Performing a 12-Lead ECG. Nursing Education Perspectives, 24(2), 70-74.
Five-item Likert response scale evaluation of the study showed positive effects on students learning outcomes and behaviours
Results showed improvement for both groups from pretest to posttest were statistically significant ( p <0.0001).
No significant difference by group on pretest, posttest or improvement scores.
No difference between groups on the consistency in performing a 12-lead ECG and found both groups performed equally well with the skill.
However the study concludes the use of a CD-ROM may be an excellent and efficient alternative to traditional teaching methods
Shepherd, I. A., Kelly, C. M., Skene, F. M. & White, K. T. (2007). Enhancing Graduate Nurses’ Health Assessment Knowledge and Skills Using Low-Fidelity Adult Human Simulation. Simulation in Healthcare, 2(1), 16-24.
Quantitative Australian study
Investigated the impact of three learning interventions on Graduate nurses’ health assessment and skills
A convenience sample of nurses’ (n=74)
Random allocation to three groups (1: self-directed learning package (SDLP) only; 2: SDLP plus two scenario based PowerPoint WORKSHOPS; and 3: SDLP plus two simulation education sessions)
Following the training students completed a systematic patient assessment upon a manikin then scored against a checklist of relevant responses.
Evaluation participant questionnaires reported the exercise was received positively.
Shapiro, M. J., Morey, J. C., Small, S. D., Langford, C. J. Kaylor, C. J., Jagminas, l., Suner, S., Salisbury, L., Simon, R. & Jay, G. D. (2004) Simulation based teamwork training for emergency department staff: does it improve clinical team performance when added to an existing didactic teamwork curriculum? Quality and Safety in Health Care, 13, 417-421.
North American single crossover, prospective, blinded and controlled observational study to determine if simulation based team training can improve clinical team performance.
Small sample ( n = 20 ) of nurses’ and emergency department physicians randomly selected from a larger convenience sample ( n = 152).
Following a didactic training on an emergency team coordination course (ETCC), emergency department staff randomly allocated into teams of experimental and comparison groups.
The experimental group received simulation training following the ETCC course
Teams were observed before and after intervention.
No statistical significance in the pretest scores between either group.
Results from the clinical observations demonstrated the experimental group showed improvement after simulation (p = 0.07).
Unfamiliar environment can distract some participants from the goal of practicing teamwork skills (Shapiro et al, (2004).
DeVita, M. A., Schaefer, J. L,. Wang, H. & Dongilli, T. (2005) Improving medical emergency team (MET) performance using a novel curriculum and a computerized human patient simulator. Quality and Safety in Health Care, 14, 326-331.
North American study to evaluated a crisis team-training course, which used human simulation training in developing multidisciplinary team skills and improving medical emergency team (MET).
Pretest and structured observation to collect data during their study.
Convenience sample ( n = 138) teams of critical care nurses, physician & respiratory therapists took part in three out of five simulated crisis scenarios Scenario outcome measures were set to determine the successful crisis management.
Secondary outcomes measured crisis task completion rate (TCR), which was a set of 29 tasks defined for each scenario.
Simulation training has a positive impact on interprofessional training and could be effective in reducing medical error
SCE Allow participants to focus on skills, organisation and problem solving within a team, rather than individually learning facts in isolation
Implications for nursing practice and education
Simulation training can be applied to all levels of experience, from novice to expert.
There’s also evidence that simulation training can be used for staff development and refresh knowledge and skills, helping to reduce knowledge and skill decay
Used within an educational framework simulation training could reduce the theory-practice gap (Shepherd et al, (2007)
Implications for nursing practice and education
Exposure to simulation training can effectively prepare nurses’ to deal with at-risk patients’ and respond to medical crisis situations, possibly reducing practice error.
Allow nurse to become acquainted with effects of new drugs within a safe supportive environment.
Simulation can be used to practice and introduce new skills and procedures.
Recommendations for using simulation as a teaching method
Simulation is only beneficial and effective in nursing if used appropriately by educators and combined with a relevant educational framework, which can be integrated into the curricula Shepherd et al (2007)
Well articulated learner outcomes with clear connection to course/ clinical objectives (DeVita et al (2005); Bremner et al, (2006)
The planning, implementing & evaluation of simulation training should be done in collaboration with the student (Bremner et al, (2006).
Measure knowledge outcomes, increased self-efficacy, skill mastery, and transferability to clinical practice, using reliable, valid data collection tools which compares simulation to traditional methods (Schoening et al, (2007)
Address the unanswered questions of whether simulation training has an impact on actual care (Shapiro et al, (2004); DeVita et al, (2005).
Explore the ideal frequency and mode of training for refresher courses
Evidence supports the use of simulation in nursing education to be an effective teaching strategy to assess and strengthen the skills and competences in nursing practice Simulation as a teaching method is complex, multifaceted and challenging
Facilitators’ – appropriate training
Adequate resources to design, develop and plan simulation training
Further research studies focus on measuring the impact simulation training has on clinical practice and patient outcomes