13CHAPTER 2
Framework for Simulation Learning in Nursing Education
As stated in the previous chapter, we believe a simulation-focused pedagogy of learning brings together an eclectic combination of learning, ecological, and nursing theory. As a result, we proposed the following framework in the first edition, rooted in the research on simulation, based on our experiences in teaching within a simulation-focused pedagogy, and combined with a collective synthesis of the experiences of the contributors to this book. The following framework outlines the components underlying our perception of simulated learning for nursing education (Figure 2.1; Daley & Campbell, 2008).
As stated in Chapter 1, Jeffries and Rogers (2007) have presented the Nursing Education Simulation Framework, which takes into account what is known about learning and cognition for the design of simulations. Since then, Jeffries’s framework has been identified as a middle range theory, and is now referred to as the NLN Jeffries Simulation Theory (Jeffries, 2015a, 2015b). Additional guidelines are now also available from National Council of State Boards of Nursing (NCSBN) for Prelicensure Nursing Programs (Alexander et al., 2015). The Framework for Simulation Learning in Nursing Education presented in this text represents a student-centered approach to learning through simulation-focused pedagogy for integration throughout the nursing curriculum. This learning takes into consideration the desired outcomes for nursing students and practitioners (including safety, excellence, and reflective practice) at varied levels and presents an additional conceptualization of making simulation real for nursing education.
Guided by ecological theory, it is important to assess what the learner brings to learning (Stokols, 1996). Students come to the academic setting with a preset combination of individual experiences and culture as a lens through which learning experiences are viewed. Think, for example, how a nursing student approaches learning after having cared for a dying family member as compared with a student without that experience. Using ecological theory, when considering a student’s personal culture, including race, ethnicity, gender, sexual identity, age, disability, geographic location, and socioeconomic status (Office of Disease Prevention and Health Promotion, 2016), and the possibility of varied health belief customs, learning can be approached in different traditional methods. Students come to nursing from varied educational backgrounds (traditional undergraduate students, second-degree students, and adult learners) and cultural and life experiences, creating a challenge for the educators to create a stimulating learning experience. In working with this diverse student population, in addition to the previously identified factors, one must also take into account the digital culture in which they live and experience learning, and move through it to reach a state of readiness for learning.
The central portion of the framework reflects the students’ interaction with nursing education. Set within the context of any nursing program’s standard accreditation and regulation competencies are three broad goals and learning outcomes, which are consistently identified. Nursing students are expected to: think critically, communicate effectively, and intervene therapeutically. 14These learning outcomes are represented in Figure 2.1 by the three circles that are overlapped by the triangle, representing simulation. Simulation as a teaching tool meets all three broad goals demonstrating the rationale and importance of integrating simulation throughout the curriculum. Allowing the students to practice in a simulated real-life situation (in real time) requires that they use critical thinking and clinical reasoning skills. By using these skills the students are able to decide on interventions that cause immediate responses in the patient (human patient simulator or standardized patient). The debriefing period allows for an evaluation of whether those interventions were effective or therapeutic, which helps students become reflective practitioners. Performing the scenarios in conjunction with classmates enhances their use of communication, delegation, and teamwork skills. The power of simulation lies in its ability to target these learning outcomes in an engaging and interactive manner beyond the didactic approach, which leads to better outcomes and more sustainable learning.
Figure 2.1 Framework for Simulation Learning in Nursing Education.
S, simulation.
Source: Adapted from Daley and Campbell (2008).
15The triangle shape itself in the framework in Figure 2.1 depicts the three fidelities discussed by Fritz, Gray, and Flanagan (2007) that contribute to making the simulation as realistic as possible: equipment fidelity, environmental fidelity, and psychological fidelity. These fidelities provide the foundation for suspension of reality that is crucial to the success of the simulation experience. Paramount to any simulation is the debriefing period in which reflection on action can take place in order to set the groundwork, and over time reinforce the formation of a reflective practitioner (Tanner, 2006).
When teaching a student within this framework, it is important to consider Fink’s (2003) six dimensions: learning to learn, foundational knowledge, the human dimension, integration, application, and caring. Represented by the hexagon in the center of Figure 2.1, these dimensions provide a support structure around which simulations can be planned and carried out. The faculty create more significant learning experiences, set the stage for an increased transfer of knowledge, and enhance the interactive component of their teaching by considering these dimensions.
As students move through a curriculum combining simulation and these pedagogical principles, the ultimate outcome is a student who learns vigilance. As an aspect of the overall concept of surveillance, nursing has focused on vigilance because of the literature on quality outcomes (Almerud, Alapack, Fridlund, & Ekebergh, 2007; Jacobs, Apatov, & Glei, 2007; Meyer & Lavin, 2005). Once mastered, vigilance results in improved safety, excellence in nursing care, and reflective practice that addresses the patient’s needs holistically. In addition, it creates a reflective practitioner who strives for lifelong learning, personal improvement, and enhanced satisfaction with his or her career (Blum et al., 2004; Haller et al., 2008; Shapiro et al., 2004; Sweeney, Warren, Gardner, Rojek, & Lindquist, 2014).
Considering the nursing shortage and issues of retention among nurses, modeling this critical thinking, clinical reasoning, and reflective practice to help students recognize their passion for nursing could have long-term effects. Mastering vigilance—recognizing when patients need immediate and effective intervention—takes time and practice. In those instances when vigilance is not mastered, simulation learning provides a safe feedback loop back through the learning experience, allowing the student (or practitioner) another chance at mastery. The overall process works toward translation of knowledge to practice and improved outcomes for the student and program, as represented at the bottom portion of Figure 2.1. In addition, the quality of practitioners is enhanced, which translates to safer care, as well as more satisfied, caring, and reflective practitioners who continue to have the ability to transform the profession of nursing. The framework brings together a caring person who, through the mastery of vigilance, reflects the three outcomes of safety, excellence, and reflective practice. Safety represents overriding concern for positive outcomes related to nursing care (e.g., no falls, pressure ulcers, or infection). Excellence in nursing is based on standards of care, quality outcomes, and evidence-based practice. Finally, reflective practice supports our conception of the caring professional who uses critical thinking, clinical reasoning, clinical judgment, and reflective debriefing in his or her daily practice (Jones, Reese, & Shelton, 2014; Kaakinen & Arwood, 2009).
Since the publication of the second edition of this text, the International Nursing Association for Clinical Simulation and Learning (INACSL) Best Practice Standards: Simulation (INACSL, 2013/2016), NCSBN multisite study (Hayden, Smiley, Alexander, Kardong-Edgren, & Jeffries, 2014), and guidelines (Alexander et al., 2015) have all been published. Much work has been done. Jeffries continues to guide simulation nurse educators in formulating high-quality simulations and providing priorities for the future to test our assumptions in the efficacy of nursing simulation (Jeffries, 2015a, 2015b). The American Association of Colleges of Nursing (AACN) BSN Essentials (AACN, 2008) recognized the importance of simulation experience to augment clinical learning and as a complement to direct care opportunities, predicting that over time evidence might emerge regarding the substitution of simulation for patient experiences within a proper balance (p. 34).
When evaluating the relevance of the framework to current practice and research, several updates and insights are appropriate. Ecological theory (Stokols, 1996) continues to provide an opportunity to examine the ecosystem in which learning occurs and provides a window into the 16complexities of the environment in which learners learn. Fink (2013) has expanded his conceptualization of creating significant learning experiences and these standards remain relevant in simulation in nursing education. The reflective thinking of a reflective practitioner is now included in research-based standards and guidelines for debriefing that are being tested (Decker et al., 2013; Dreifuerst, 2009, 2012; Shinnick, Woo, Horwich, & Steadman, 2011). The research in nursing on vigilance through simulation continues and includes studies on the deteriorating patients in failure-to-rescue scenarios and crisis resource management (Blum et al., 2004; Cooper et al., 2010; Endacott et al., 2012; Fisher & King, 2013; Haller et al., 2008; Kelly, Forber, Conlon, Roche, & Stasa, 2014; Liaw, Scherpbier, Klainin-Yobas, & Rethans, 2011; Merriman, Stayt, & Ricketts, 2014). Similarly, research has explored the assessment and evaluation of communication, both practitioner to patient (Campbell, Pagano, O’Shea, Connery, & Caron, 2013; O’Shea, Pagano, Campbell, & Caso, 2013; Pagano et al., 2015), and during patient handovers (Enlow, Shanks, Guhde, & Perkins, 2010; Fay-Hillier, Regan, & Gallagher Gordon, 2012; Härgestam, Lindkvist, Brulin, Jacobsson, & Hultin, 2013; Hill & Marcellus, 2015). Chapter 4 discusses teaching and evaluation of communication with simulation. The outcomes remain the same as illustrated by the framework, but we have more research substantiating these results in simulation education.
Kolb (1984) contributes to our understanding of simulation in nursing education and has recently provided new insights. Research is beginning to show that although debriefing is often the most significant experience in a simulation experience, creating a feedback loop or a “redo,” as depicted in the framework, solidifies the simulation experience as a significant learning moment that may be more transferable to actual patient care. In applying Kolb’s theory of experiential learning, simulations have included the first three essential stages of the theory: concrete experience, reflective observation, and abstract conceptualization, which fit well with prebriefing, participating in a simulation, and debriefing. The fourth stage of active experimentation may need to be considered and would allow students to return to the scenario to try again or “redo” to allow a full integration of theory to practice, transforming learning into “new ways of thinking and new behaviors” (Lisko & O’Dell, 2010). Including a session to return to the side of the HPS and try again may prove beneficial. Although many simulations end before that step, we recommend extending the simulation experience to include this fourth stage and may provide the answer to the question: Is simulation transferable to actual performance of the student and professional nurse?
How far we have come in so little time! Challenges still exist, such as assessment, evaluation, and the wise use of resources for simulation-focused pedagogy. It is our hope that our work, the work of our contributors, and our framework assist in moving nurse educators along in their journey to integrate simulation throughout their nursing curriculum. Go forth and simulate! Faculty, students, administration, and, most important, our patients reap the benefits! The depth, breadth, and value of this book continues to be in the stories told, the ideas shared, and the variety of teaching scenarios now available to all.
REFERENCES
Alexander, M., Durham, C. F., Hooper, J. I., Jeffries, P. R., Goldman, N., Kardong-Edgren, S. S., … Tillman, C. (2015). NCSBN simulation guidelines for prelicensure nursing programs. Journal of Nursing Regulation, 6(3), 39–42. doi:10.1016/S2155-8256(15)30783-3
Almerud, S., Alapack, R. J., Fridlund, B., & Ekebergh, M. (2007). Of vigilance and invisibility—Being a patient in technologically intense environments. Nursing in Critical Care, 12(3), 151–158.
American Association of Colleges of Nursing. (2008). The essentials of baccalaureate education for professional nursing practice. Washington, DC: Author. Retrieved from http://www.aacnnursing.org/Portals/42/Publications/BaccEssentials08.pdf
Blum, R. H., Raemer, D. B., Carroll, J. S., Sunder, N., Felstein, D. M., & Cooper, J. B. (2004). Crisis resource management training for an anaesthesia faculty: A new approach to continuing education. Medical Education, 38(1), 45–55.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
