Zacharias Capstone final

Running head: HIGH FIDELITY SIMULATION 1
High Fidelity Simulation in Undergraduate Nursing Education:
Communication and Critical Thinking Skills
Elizabeth K. Zacharias BSN, RN
Lourdes University

IMPACT OF HIGH FIDELITY SIMULATION 2
Abstract
The problem identified in this paper is that improved techniques must be utilized to ensure that
graduate nurses are able to effectively transition to nursing independently with professional
communication and critical thinking skills. When nurses feel more confident and competent in
their skills, patient care improves. Being able to communicate with all members of the healthcare
team allows a registered nurse to better advocate for their patient needs. An extensive literature
review has been performed to determine themes. The focus of this literature search was to
determine whether high-fidelity simulation improves competence and confidence in the new
graduate nurse. This information was then used to develop a curriculum tool to be presented to
baccalaureate nursing programs to improve the utilization of high fidelity simulation throughout
their programs.

High Fidelity Simulation in Undergraduate Nursing Education:
Communication and Critical Thinking Skills
Many graduate nurses have difficulty with communication and utilizing their knowledge
in the practice setting. High fidelity simulation exercises provide a more realistic approach to
nursing care and its challenges. Opportunities to use critical thinking skills, interact with the
multidisciplinary team, and develop communication with physicians are all able to be explored
with high fidelity simulation (Richardson and Claman, 2014). It is believed that extensive
immersion in this learning technique will allow for better transition to independent nursing
practice.
High-fidelity simulation is the use of mannequins and equipment within a controlled
educational practice environment. High-Fidelity Simulation is supported by the Cognitive
Learning Theory: Assimilation Theory. This theory states that students make experiences fit
what they already know and develop that “Aha Moment.” Students have more control over what
occurs in these simulations and learn from their decisions (Candela, 2012; Bradshaw, 2014; and
Braungart, Braungart, and Gramet, 2014). Fidelity refers to how close to reality a simulation is.
High-Fidelity simulation refers to simulations that are extremely realistic and contain a high
level of interactivity and realism (Jeffries and Clochesy, 2012). Some strengths of Mid to High-
Fidelity Simulation are active involvement of students, effectiveness as a competency check,
correction of errors can be discussed immediately, and it creates a standardized experience for all
students (Jeffries and Clochesy, 2012). Some limitations of Mid to High-Fidelity Simulation
include the time commitment of faculty, the need for faculty to design all aspects of simulation,
the time to experience the simulation and reflect, faculty orientation to equipment, and expense
for the facility (Jeffries and Clochesy, 2012). The mannequins are able to ‘speak’, simulate vital

signs and disease processes. Students are able to perform skills, work on communication with
each other and the patient, and learn confidence in their skills.
Problem Statement and Research Question
The problem identified is that improved techniques must be utilized to ensure that
graduate nurses are able to effectively transition to nursing independently with professional
communication and critical thinking skills. This problem specifically relates to new graduate
nurses in the acute care setting. Graduating nurses that are better prepared for the challenges of
the acute care setting will allow them to transition easier to independent, competent, and
confident care. Learning to communicate well with colleagues, whether physicians, fellow
nurses, or support therapies will improve patient satisfaction and care. The use of high fidelity
simulation has been shown to increase student’s confidence, technical skills and their ability to
reflect on their experience (Negrão Baptista, Amado Martins, Carneiro Ribeiro Pereira, and
Mazzo, 2014). The research question pertaining to this problem is, “Does the use of high fidelity
simulation improve nursing communication and critical thinking skills for the graduate nurse in
the acute care setting?”
Significance to Nursing Practice
When nurses feel more confident and competent in their skills, patient care improves.
Being able to communicate with all members of the healthcare team allows a registered nurse to
better advocate for their patient needs. The ability to practice scenarios in the safety of high
fidelity simulation allows for improvement of skills and allows room for errors to improve the
learning experience. Reflection following simulation is a great technique to foster improvement.

Literature Review
Communication and critical thinking are essential to the development of the professional
nurse. With increased acuity of patients, the nurse is required to have a firm grasp of this skill in
order to effectively care for his/her patient (Grant, Dawkins, Molhook, Keltner, and Vance,
2014). Critical thinking is a vital component of nursing education and should be incorporated
throughout the curriculum (Smith and Roehrs, 2009; Kaddoura, 2010; Smithburger, Kane-Gill,
Kloet, Lohr, and Seybert, 2013). Use of this simulation experience provides a safe learning
environment for students to improve their skills (Kaddoura, 2010).
Good communication is necessary to work with patients, families, and the
multidisciplinary team. Lack of communication greatly influences employee morale, turnover,
and employee satisfaction, which can effect patient care (Di Delupis, Pisanelli, Di Luccio,
Kennedy, Tellini, Nenci, Guerrini, Pini, and Gensini, 2014; Holtschneider, 2007). Experience
with development of this skill is important in nursing curricula (Kameg, Clochesy, Mitchell, and
Suresky, 2010). The use of high-fidelity simulation aids in assessment of skills, improves
communication, and improves patient care (Kaddoura, 2010).
Debriefing following simulations allows students and educators to evaluate performance
and improve skills (Kaddoura, 2010). Facilitating this discussion is a primary role for nurse
educators (Holtschneider, 2007). While best debriefing practices are being assessed, the use of
high-fidelity simulation with debriefing has proven to increase patient safety, improve
assessment skills, develop critical thinking skills, and improve communication among the team
members (Smith and Roehrs, 2009; Grant et al., 2014; Kaddoura, 2010). Blum, Borglund, and
Parcells performed a study comparing students within a traditional learning environment versus
students using high-fidelity simulation in their education (2010). Their study determined that

there was no statistical significance in self-confidence scores between these two groups (Blum et
al., 2010). It was decided that further development of the simulation experiences required repeat
evaluation.
Kaddoura performed a literature review, as well as a study, to determine how new nurses
perceived their simulation experiences after a new training program was developed. He primarily
focused on their critical thinking skills and confidence in their new practice setting (Kaddoura,
2010). Interviews of these nurses were completed and the qualitative data revealed three main
themes. The realistic patients allowed the nurses to narrow their theory to practice gap
(Kaddoura, 2010). The new graduate nurses also reported feeling they improved their critical
thinking skills and communication skills, both during the simulation and with reflection during
debriefing (Kaddoura, 2010). The third theme that surfaced was the feeling of safety in the
simulation environment. The nurses felt they were able to improve their confidence level when
they knew they were performing in a safe environment (Kaddoura, 2010).
Kameg, et al., studied how high-fidelity simulation enhanced student self-efficacy of
communication skills. Following simulation experiences, it was determined that their perceptions
of improved skills were significant (Kameg et al., 2010). The students reported increased
understanding of nursing concepts, improved critical thinking skills, narrower theory to practice
gap, and improved confidence (Kameg et al., 2010).
Smithburger, et al., developed a multidisciplinary team approach to high-fidelity
simulation. Following a series of scenarios, the pharmacy, medical, nursing, social work, and
physician assistant students were given a survey to evaluate how high-fidelity simulation
improved team communication (Smithburger et al., 2013). The students reported improved

communication and increased confidence, as well as an interest in interprofessional
communication (Smithburger et al., 2013).
Theoretical Framework
The focus of this research is to determine whether high-fidelity simulation improves
competence and confidence in the new graduate nurse. Benner’s model of Novice to Expert
(1984) fits well with this topic. As educators, it is important that our teaching guides students
through the novice to expert stages while utilizing various teaching methods. Benner’s model
separates into five levels of competency. The first level is the novice nurse, who concentrates on
concrete information, such as vital signs and weight (Waldner and Olson, 2007). This level does
not focus on any outside information. The second level is the advanced beginner, who is able to
recognize that these vital signs are related to a disease process. The third level is the competent
nurse. This nurse is able to recognize symptom management in the long term care of the patient.
This nurse feels a sense of responsibility to the patient (Waldner & Olson, 2007). The fourth
level is proficiency, where this nurse is able to notice changes in the patient condition and
determines her actions based on that decline. Lastly, the expert level is where a nurse has
developed an intuition that allows him/her to perform at a more efficient level than the previous.
This nurse has extensive knowledge and experience to assess situations (Waldner & Olson,
2007).
It has been discussed that the new graduate nurse should perform, at minimum, in the
advanced beginner role. Performance at the competent level is preferred (Waldner & Olson,
2007). The use of simulation in nursing programs is useful in advancing through these levels
(Waldner & Olson, 2007). Novice nurses are able to enhance their clinical skills using
simulation. The ability to debrief will allow these students to see the bigger picture to make

connections with their classroom learning. The challenge to the novice and advanced beginner’s
confidence allows them to grow and improve their critical thinking skills (Waldner & Olson,
2007). More complex simulations can be created as a student reaches competence. Pushing them
out of their comfort zone allows them to expand their knowledge and requires them to adapt their
care (Waldner & Olson, 2007).
Project Design
The aim of this research was to determine the relationship between clinical simulation
and communication, confidence and competence. An extensive literature review was performed
to determine themes. This information was utilized to formulate an outline for nursing curricula
that incorporates simulation. A recommendation will be made to baccalaureate nursing programs
in order to improve simulation experiences and effectiveness. Future research will hopefully
implement and evaluate this analysis for improvement.
A systematic literature search was performed using the Academic Search Complete,
CINAHL Plus with Full Text, Health Source: Nursing/Academic Edition, MEDLINE with Full
Text databases and ProQuest Nursing & Allied Health Source databases. The searches performed
used the search terms: simulation, high fidelity, confidence, competence, communication,
undergraduate, nursing, novice, multidisciplinary, interdisciplinary, graduate, and nurse.
The search was narrowed to articles that were peer-reviewed and used evidence based
practice, including the dates of January of 2005 through November of 2015. A total of 32 articles
reviewed, with 21 being utilized to reach saturation on the topic. Quality of the search articles
was evaluated using a hierarchy. Studies were scored as high, medium, and low quality with low
quality articles being omitted. The Critical Appraisal Skills Programme (CASP) tool for
Systematic Reviews, CASP tool for qualitative articles, and CASP tool for Cohort Studies were

used to evaluate the articles for quality ratings. The research focused on communication and
confidence related to high fidelity simulation versus skills. Articles that focused on skill-based
evaluation were excluded.
Themes
Safe Learning Environment
Four main themes were discovered while evaluating the research materials. The first
theme was that simulation can be used to provide a safe learning environment. This allows
students the freedom to practice their skills and use critical thinking in a controlled environment
(Candela, 2012; Bradshaw, 2014). These students are able to practice their skills without fear of
injuring a real patient. The simulations are used to guide the critical thinking of the students and
they drive the experience and outcomes. They experience a realistic acute care environment,
complete with equipment and supplies. Simulation experiences are able to be created based on
different clinical presentations, communication scenarios, or to practice delegation. It has been
shown that confidence improves greatly in this environment without fear of making mistakes
(Braungart, Braungart, & Gramet, 2014).
Employee Turnover, Morale, and Satisfaction
The second theme that emerged was the overwhelming link to employee turnover,
morale, and satisfaction. Students who experienced high fidelity simulation during their
undergraduate education were shown to feel more confident and competent in their nursing
practice (Di Delupis, Pisanelli, Di Luccio, Kennedy, Tellini, Nenci, Guerrini, Pini, & Gensini,
2014). This allowed them to feel more comfortable in their work environment and allowed them
to gain the acceptance of their coworkers. These new graduates were found to be more satisfied
at their jobs and remain in their entry nursing positions for longer periods of time (Holtschneider,

2007). This has been a known issue in our local health care system. We have new graduate
nurses that attend a nursing residency program for the 20-40 weeks, and then transfer on to
another position, or rarely leave nursing altogether. There is now a contract in place to retain
these new registered nurses for a minimum of 18 months. With the amount of money that goes
into financing these nursing residency programs, this certainly seems like an important aspect to
review.
High Fidelity Simulation with Debriefing
The third theme was the importance of debriefing following the simulation experience.
This debriefing has been proven to increase patient safety and improve assessment skills
(Kaddoura, 2010). The videotaping of the simulation allows for the students and instructors to
review the chain of events. Students are able to see the areas they performed well and are able to
correct their weaker areas. This way they are able to view their mistakes and discover their own
solutions. Simulation allows the students to improve their communication skills and develop
their critical thinking skills (Holtschneider, 2007). This experience allows the students to be
more in control of their learning while remaining in a safe learning environment. Their errors in
this learning environment will not cause harm to patients and will hopefully improve their future
patient care. The students are able to discover issues that they will be more aware of in the
future, and often seeing these mistakes is what sticks in their mind.
Interprofessional Communication Skills
The fourth theme revealed an improvement in interprofessional communication skills
(Smithburger et al., 2013). Students can role play as different members of the healthcare team in
order to improve their communication skills. This allows them to practice requesting patient
orders, updating physicians on patient condition, communicating with pharmacy staff, hand-off

reporting, etc. These communication skills were reported to be lacking from many undergraduate
nursing curricula (Smithburger et al., 2013). Working toward better communication skills will
improve patient care. It would be excellent to incorporate students from all disciplines into
simulation experiences to benefit all. Often the first time these disciplines meet is during a
critical patient situation.
Conclusion
Simulation experiences should be an essential part of the undergraduate nursing
curriculum. They are currently used to promote skill development, but are not utilized to their
full potential. Communication skills are so important in nursing practice. Teaching our students
these skills throughout nursing school will allow them to be more confident upon graduation.
The included simulation experiences are just a few examples to help incorporate communication,
critical thinking, and confidence in the learning environment.

References
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student self-confidence and clinical competence. International Journal Of Nursing
Education Scholarship, 7(1), doi:10.2202/1548-923X.2035
Bradshaw, M. (2014). Effective Learning: What Teachers Need to Know: Innovative Teaching
Strategies In Nursing and Related Health Professions. Burlington, MA: Jones & Bartlett
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Practice. Nurse as Educator: Principles of Teaching and Learning for Nursing Practice.
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Kameg, K., Howard, V., Clochesy, J., Mitchell, A., & Suresky, J. (2010). The impact of high
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Negrão Baptista, R. C., Amado Martins, J. C., Carneiro Ribeiro Pereira, M. F., & Mazzo, A.
(2014). High-Fidelity Simulation in the Nursing Degree: gains perceived by
students. Revista De Enfermagem Referência, 4(1), 131-140. doi:10.12707/RIII13169
Richardson, K. J., & Claman, F. (2014). High-Fidelity Simulation in Nursing Education: A
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Smithburger, P. L., Kane-Gill, S. L., Kloet, M. A., Lohr, B., & Seybert, A. L. (2013). Advancing

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Waldner, M., & Olson, J. (2007). Taking the patient to the classroom: applying theoretical
frameworks to simulation in nursing education. International Journal Of Nursing
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