Clinical simulations: an experiential, student-centered pedagogical approach

Pamela R. Jeffries, PhD, RN, FAAN, ANEF and John M. Clochesy, PhD, RN, FAAN, FCCM

Clinical simulation offers nurses, students, and health professionals the opportunity to learn in varied situations that are comparable to actual patient encounters while maintaining a safe learning environment for students (Dobbs, Sweitzer, & Jeffries, 2006; Katz, Peifer, & Armstrong, 2010). Simulation technology provides a risk-free, controlled learning setting that supports the learners’ transfer of classroom and skills laboratory knowledge to realistic patient interactions (Halstead, 2006; Medley & Horne, 2005). In many areas, nurse educators have been challenged to find appropriate clinical sites and clinical experiences for nursing students to meet curricula competencies, and thus nurse educators are exploring alternative strategies for clinical preparation for nursing students. Clinical simulation technology is rapidly expanding and nursing programs are making large investments in equipment and learning space. As simulations and related teaching and learning strategies move into nursing programs, the nurse educator must be prepared to teach using this methodology. This chapter discusses clinical simulations as an experiential, student-centered pedagogical approach. The chapter begins with an overview of types of simulation—the purposes, challenges, and benefits of clinical simulations—and concludes with information about planning, implementing, and evaluating simulations as they are integrated into courses and curricula. Emphasized are (1) the types of clinical simulations being developed and implemented in nursing programs; (2) challenges and benefits to student learning, thinking, and practice; (3) a framework and steps to consider when developing and using clinical simulations; and (4) the evaluation component to consider when implementing simulations in the teaching–learning environment.

Simulations

Simulations are activities or events that mimic real-world practice (Seropian, 2003). Simulations are used when real-world training is too expensive, occurs rarely, or puts participants (or patients) at unnecessary risk. Simulations provide the opportunity for students to think critically, problem-solve, use clinical reasoning, and care for diverse patients in a nonthreatening, safe environment. Today’s learners must be prepared for the complexity and fast pace of the care environment, able to solve problems quickly by making appropriate assessments and decisions and to intervene to achieve desired outcomes. Incorporating simulations into a nursing curriculum as a teaching and learning strategy offers nurse educators the opportunity to support learners’ educational needs by providing them with an interactive, practice-based instructional strategy.

Full-scale patient simulations using sophisticated, high-fidelity patient simulators provide a high level of interactivity and realism for the learner. Less sophisticated, but still educationally useful, are computer-based simulations in which the participant relies on a two-dimensional, focused experience to solve problems, perform skills, and make decisions during the clinical scenario. Studies have shown that the two-dimensional experience has merit in terms of positive learning outcomes and skill acquisition (Jeffries, Woolf, & Linde, 2003). Partial task training devices such as IV arms and haptic (force feedback) IV trainers are used in simulations for psychomotor skills. The learner is able to practice a skill repeatedly before performing it on a real patient. The partial task trainers typically ensure a satisfactory rate of achievement of objectives and benefit to the participant. Studies have shown that after having used these task trainers, participants demonstrate a psychomotor skill and use that skill set in the real patient environment (Engum & Jeffries, 2003). Programs or courses in which the task trainers are used include clinical laboratory courses and modules during which specific skill sets and goals need to be obtained. Another approach to learning is the use of two-dimensional CD-ROMs to provide interactive practice with skills.

Types of simulation technologies

Simulations variously involve role playing, standardized patients (actors), interactive videos built on gaming platforms, and manikins to teach procedures, decision making, and critical thinking in realistic environments (Ryan et al., 2010). There are a variety of technology-based simulations to support student and novice nurses. They include computer-based interactive simulations, haptic partial task trainers, and digitally enhanced manikins. Haptic trainers use force feedback to provide opportunities to develop psychomotor skills. In addition to types of simulations categorized by the equipment or manikin used, there are simulations categorized by the type of pedagogy used when implementing the simulations. These types of simulations are described below.

Hybrid simulations

A hybrid simulation is the combination of a standardized patient and the use of a patient simulator in one scenario to depict a clinical event for the learner. For example, the simulation scenario may begin with the student performing a health history on a standardized patient who has just arrived in the emergency department after having been involved in a motor vehicle accident. As the case evolves, the activity shifts to a patient simulator because of the clinical symptoms that need to be demonstrated by the manikin to reflect reality. This is a hybrid simulation because the history is being performed on a standardized patient and then the scenario shifts to a patient simulator, where the patient is now experiencing “hypovolemic shock” that is being reflected in the vital signs and other clinical findings of the manikin.

Unfolding case simulations

Another type of simulation is the unfolding case. Unfolding cases evolve over time in an unpredictable manner. An unfolding case may include three to four events that build on each other, providing students with a view across a clinical event, a hospitalization, or a view across the life span (Page, Kowlowitz & Alden, 2010). Purposes of unfolding cases vary, but a few include:

1. To demonstrate hierarchal order so the learner can view the health disruption progression and symptom management. For example, the first scenario demonstrates the patient being admitted with a head injury due to a fall; focused neurological assessment is needed. The unfolding case leads to a second scenario, in which the patient experiences specific neurological signs (e.g., severe headache, widening pulse pressure). The third case occurs postcraniotomy and involves care of the patient after the subdural hematoma was removed.

2. To visualize and prioritize hospital trajectory and care of a patient that progresses. For example, the patient is admitted through the emergency department, with the learner performing an assessment. The second scenario depicts the patient being admitted to the progressive care unit and the third scenario is designed for the learner to prepare the patient with discharge instructions.

3. To provide the learner with a view across the life span, showing the impact of the health disruption or disease process and nursing interventions required for a particular patient. For example, the first scenario depicts a patient newly diagnosed with chronic obstructive pulmonary disease (COPD). The second scenario progresses to the patient having compromised gas exchange related to COPD, and then the third scenario depicts end-stage disease with a focus on end-of-life care.

4. To serve as a mechanism to include a variety of important assessments and findings where one event leads to another. For example, the first scenario focuses on hypotension and subtle findings of sepsis and the second scenario centers on the critically ill patient with sepsis and hypotension.

Several organizations have developed unfolding case studies related to particular topics that are available at no cost to faculty. Four unfolding cases that focus on older adults and address the complexity of decision making about their care can be found at http://www.nln.org/facultydevelopment/facultyresources/ACES/index.htm; unfolding cases related to patient safety can be found at the Quality and Safety Education for Nurses site at http://www.qsen.org.

Standardized patients

Standardized patients are live actors trained to portray the role of a patient according to a script or to clinical scenarios written by the faculty. The actors become the patients, demonstrating clinical symptoms and responses of real patients. A variation of the standardized patients instructional strategy is the use of these types of simulations to evaluate physical assessment skills, history taking, communication techniques, patient teaching, and types of psychomotor skills or objective structured clinical examination (OSCE).

In situ simulations

In situ simulation is a type of simulation that involves training performed in a real-life setting where patient care is commonly provided (Dismukes, Gaba, & Howard, 2006). The aim of this type of simulation is to achieve high fidelity (realism) by performing the simulations in actual clinical settings. Typically, the simulation-based experiential learning focuses on interdisciplinary professional teams. Practicing professionals are well versed in their particular field, possess a fair amount of experience, and prefer their learning to be problem-centered and meaningful to their professional lives. Adults learn best when they can immediately apply what they have learned. Traditional teaching methods (e.g., a teacher imparts facts to the student in a unidirectional model) are not particularly effective in adult learning because it is important for adults to make sense of what they experience or observe.

Virtual simulations

Simulations can also take place in virtual environments. One commonly used environment is Second Life, a virtual world accessible by the Internet that enables its users, called residents, to interact with each other through avatars. In this simulated world, residents can explore, meet other residents, socialize, participate in individual or group activities, and create services for one another or travel throughout the world. The software is a three-dimensional modeling tool that attempts to depict reality for the users. Second Life is used as a platform for education by many institutions, such as colleges, universities, libraries, and government entities. For the top 10 health care–related virtual reality applications, go to http://scienceroll.com/2007/06/17/top-10-virtual-medical-sites-in-second-life/.

Purpose of simulations

Clinical simulations in nursing education can be used for many purposes, for example, as a teaching strategy or for assessment and evaluation. However, one of the most important reasons that educators use simulations is to provide experiential learning for the student. Students can be immersed in a simulation, where they can actually portray the primary nurse, a newly employed nurse in orientation, or whatever role within the scope of practice of nursing the learner is assigned.

Experiential learning

The use of simulation corresponds with a shift from an emphasis on teaching to an emphasis on learning (Dunn, 2004; Jeffries, 2005) in which the faculty facilitate learning by encouraging students to discover, or construct, knowledge and meaning. David Kolb (1984) and others (Sewchuck, 2005; Svinicki & Dixon, 1987) suggest that the experiential learning cycle is a continuous process in which knowledge is created by transforming experience. Individuals have a concrete experience, they reflect on that experience (reflective observation), they derive meaning (abstract conceptualization) from the experience, and they try out or apply (active experimentation) the meaning they’ve created, thus continuing the cycle with another concrete experience.

When making a shift in approach from a focus on teaching to a focus on learning, goals of the educational program serve as the framework for the development of specific learning activities. For example, both nursing students and nurses entering professional practice find it difficult to transfer learning into clinical practice. The use of simulation allows students to experience the application of theory in a safe environment where mistakes can be made without risk to patients.

The use of highly realistic and complex simulation is not always an appropriate educational approach. The literature suggests the use of low-fidelity and noncomplex simulated experiences with beginning students (Janes & Cooper, 1996; Schumacher, 2004). In simulation centers, beginning students can use low-fidelity simulation to work on attainment of foundational skills, including effective communication with patients, psychomotor skill performance, and basic assessment techniques. With task trainers or standard manikins, students can practice procedural skills and caregiving in a safe environment that allows them to make mistakes, learn from those mistakes, and develop confidence in their ability to approach and communicate with patients in the clinical setting. In addition, students benefit from the opportunity to work with technologically sophisticated equipment such as clinical information systems and hemodynamic monitoring systems in the educational setting before encountering such equipment in the clinical setting.

Advanced nursing students benefit from high-fidelity simulations that are complex, realistic, and interactively challenging experiences that support them in developing and practicing teamwork and decision-making skills. With patient simulators, for example, students can practice complex assessment skills involving a wide range of complex cardiac rhythms, variations in QRS morphology, changes in blood pressure, normal and abnormal breath sounds and patterns, heart sounds, pulses, bowel sounds, and computer-generated sound and vocalizations that provide subjective information. Faculty can create scenarios and program equipment to simulate serious clinical situations such as respiratory arrest or aberrant cardiac rhythm that may require an emergent response. More recently, the use of simulation in mental health situations has increased (Brown, 2008; Kameg, Howard, Clochesy, Mitchell, & Suresky, 2010; Kameg, Mitchell, Clochesy, Howard, & Suresky, 2009). As students respond to these situations, they demonstrate their abilities to establish priorities, make decisions, take appropriate action, and work successfully as part of a team (Reese, Jeffries, & Engum, 2010). Within the simulated environment, advanced students can demonstrate application of learning because they are no longer merely acquiring knowledge and skills. Students learn from the simulated practice without the need for faculty stepping in to correct and control the situation. High-fidelity simulation allows all students the opportunity to experience a baseline set of clinical scenarios, including those that are uncommon or rare. Students can practice a scenario repeatedly and use simulations for remediation, which enhances their preparation for clinical practice.

Clinical simulations as a teaching–learning strategy

With the advent of technologically advanced approaches, learning resource centers and clinical simulation centers have been developed to better prepare students for and maximize their learning experiences with patients in the clinical setting (Bearnson, 2005). Experiential learning through simulation affects patient care, health, and safety. Interactive experiences through the use of clinical simulations engage students through participation, observation, and debriefing (Rothgeb, 2008).

Forces influencing emergence of simulation in nursing education

Nurse educators have used low-fidelity simulation such as manikins, role play, and case studies for decades. The introduction of high-fidelity simulation (in the form of affordable, portable, and versatile human patient simulators) in the late 1990s transformed health care education and appears to be one of the technologies of the future. Using simulation in nursing education as an instructional strategy is supported not only by a constructivist approach to education but also by lessons learned from those preparing pilots, military special forces teams, and students preparing for administering anesthesia or performing surgery. Across disciplines, unpredictable situations cause critical thinking challenges, including making the right assessment, taking timely action, and performing competently (Macedonia, Gherman, & Satin, 2003). Simulation has the advantages of posing no safety risks to patients and not provoking ethical dilemmas because it provides a wide range of experiences.

The dynamics of the hospital environment make it a less than ideal educational setting. Increased severity of illness of patients, decreased length of stay, heightened technology, patient safety initiatives, and workforce shortages all decrease the ability of staff nurses, even if expert, to mentor students. With increased enrollment in schools of nursing, nurse administrators are unable to accommodate all requests for student placements. To identify and resolve threats to patient safety, simulation has been used to identify latent threats to patient safety and to test potential resolutions (Hamman et al., 2010; Henneman et al., 2010). In a recent study, it was discovered that nursing students relied heavily on automated devices to obtain vital signs (Shepherd, McCunnis, Brown, & Hair, 2010). The use of simulation allows for a reliable way to assess students’ skill at obtaining vital signs over a wide range of values. Clinical learning using simulation has emerged because of all of these forces.

Simulations used for assessment and evaluation

With the rapid advancement of simulation technologies, the potential of using simulations for assessment and evaluation has expanded greatly. While more traditional forms of assessment continue to be employed—for example, pretesting and posttesting using multiple-choice tests—simulation-based assessments have gradually worked their way into the evaluation process, both in a formative manner, as part of an educational activity or training, or in a summative manner, as part of a certification process or licensure obtainment (Boulet, 2008; Boulet et al., 2003).

When simulations are being used for assessment or evaluation, the activities fall into two broad categories—“low-stakes” and “high-stakes” situations—depending on the significance of the evaluation (Boulet & Swanson, 2004). Low-stakes assessments are situations in which the simulation is used by the learner and faculty to mark progress toward personal, course, or program learning goals. High-stakes assessments include licensing and certification examinations, credentialing processes, and employment decisions (Jeffries, Hovancsek, & Clochesy, 2005). Simulation technologies used for assessment range from case studies and standardized patients (e.g., OSCEs) to haptic task trainers and high-fidelity human simulators.

As with any type of assessment, faculty must consider the issues of validity and reliability (Boulet et al., 2003; Clauser, Kane, & Swanson, 2002). For assessments in low-stakes or learning situations, construct and concurrent validity should be addressed. Construct validity is the degree to which an assessment instrument measures the dimensions of knowledge or skill development intended. Concurrent validity is determined by evaluating the relationship between how individuals perform on the new assessment (in this case a simulation) and the traditional (standard) assessment instrument (Pugh & Youngblood, 2003). An assessment with high concurrent validity, for example, is one in which the learner’s simulator assessment score is comparable to his or her score when performing the same examination on a standardized patient scored by using a checklist.

Predictive validity is required for simulations used in assessments in which licensure, certification, or employment are at stake. Determining predictive validity in high-stakes assessment is a complex process. Predictive validity is the extent to which performance on a particular simulation predicts future performance, such as clinical decision making or psychomotor skills. Evaluating predictive validity requires that, in addition to current performance, the clinical skill or decision making of specific individuals be tracked over time. There has been little research and evidence-based information specifically focused on quantifying the impact of simulation-based assessment activities on student or practitioner learning.

Simulations also are being used to assess and evaluate students’ clinical skill competencies and clinical decision-making capabilities. Using standardized patients to assess the clinical skills of medical students and residents has become widespread (Chambers, Boulet, & Gary, 2000). OSCEs are clinical examinations that vary in format but mostly include a set period of time for the student to assess and interact with a standardized patient, an actor or actress hired to portray a certain type of patient with a specific diagnosis and clinical symptoms. Wilson, Shepherd, and Pitzner (2005) used the low-fidelity human patient simulator to acquire and then assess nurses’ health assessment knowledge and skills. The use of the low-fidelity manikins proved to be an effective tool to assess for health assessment skills. Miller, Leadingham, and Vance (2010) used the human patient simulator to meet learning objectives across core nursing courses.