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Simulation in Nursing Education. Margaret Saunders RN, BSN, CCRN. ABSTRACT.

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Simulation in nursing education

Simulation in Nursing Education

Margaret Saunders RN, BSN, CCRN


Health Care in the United States is not as safe as most would think. There is an alarming rise in morbidity and mortality among hospitalized patients, causing increase concern about professional competency(Durham & Alden, 2008). Given that nurses are the largest group of health care providers, they are under scrutiny to provide safe, quality, and effective patient care. Nursing education programs across the country are faced with the challenge of providing students with the skills to function and perform in a fast paced, highly complex environment. The use of clinical simulation in nursing education provides for such challenges. Simulation can incorporate a diversified learning strategy and help prepare students for a complex patient population. As the use of simulation continues to grow, there is a need to increase the credibility of such strategy for increasing critical thinking. This research can help provide evidence for the use of simulation to increase critical thinking among associate degree nursing students.

Purpose of the study

  • The purpose of this study will be to determine if exposing associate degree nursing students to simulation in addition to traditional clinical would lead to an increase in critical thinking scores on the HSRT.

Research question hypothesis

  • This study aims to test whether exposing nursing students to simulation scenarios, in addition to participating in traditional clinical, would lead to an incrementally increase in critical thinking scores on the Health Science Reasoning Test (HSRT).

  • It is hypothesized that the experimental group of students will achieve higher overall scores on the Health Sciences Reasoning Test (HSRT) than that of the control group.


  • The use of Patricia Benner’s theory was used in the formation of this study. Benner’s Novice to Expert model of clinical development outlines 5 steps to skill attainment: novice, advanced beginner, competent, proficient and expert (Benner,1984). In this study students will apply the theory with the use of preparation prior to simulation, participating in scenarios, and developing the skills and knowledge. As students progress through the program they move from the novices to becoming competent in providing direct patient care.


  • Variables identified in this study would include: simulation-based learning and the Health Science Reasoning Test.

  • The use of simulation-based learning will act as the independent variable. While the outcome or dependent variable is that of increase in Health Science Reasoning Test which indicates an increase in critical thinking.

Key terms

  • Simulation is a technique or device that attempts to create characteristics of a real patient experience(Durham & Alden, 2008). It may also refer to the activities that mimic the reality of a clinical environment and used in the demonstration of procedures or the promoting of clinical judgment and critical thinking. The use of simulation provides for risk free learning for nursing students(Dougherty, 2011). Simulation can be categorized as low-fidelity to high-fidelity.

    • Low-fidelity simulation may consist of using an orange to practice injections prior to performing on a patient.

    • High-fidelity simulation is the use of realistic anatomically correct mannequins to imitate human responses in real-time.

Key terms1

  • Health Sciences Reasoning Test (HSRT) is a computer based standardized testing instrument to assess the critical thinking skills of health care professionals. This test was chosen due to it’s quantitative assessment approach(Facione & Facione, 2006).

  • Critical thinking refers to the metacognitive and evaluative processes that guide the nurse’s response to the patient problems. Critical thinking skills are the ability to evaluate information and situations within their unique context to make a decision.

  • Debriefing is the discussion of the various learning experiences by each student. The use of debriefing will allow students to pull from each other ad have time to ask questions of the scenarios or clinical experiences.

Operational definitions

  • Critical thinking represents skills of assessment, intervention, and evaluation to diagnosis and treat patients. This is defined as a score > 25 indicating very strong critical thinking while 15-24 indicates critical thinking skills that are suitable for learning and development of knowledge.

  • Associate degree of nursing is an intensive nursing program combined with education needed to create a nurse who can use critical thinking and problem-solving skills to serve the public in health care. The graduate is eligible to take the licensure examination for employment as a registered nurse. For this study students will be in the second semester of a two year program.

  • Simulation is an activity or event that replicates real life patient care. For this study simulation refers to the use of high-fidelity simulation.

Literature review

  • The following databases were search for related articles: CINAHL, ERIC, and Proquest. Keywords used in the search consist of : patient simulation, nursing education, nursing simulation, high-fidelity simulation, and nursing simulation research. Of the articles reviewed most were noted to be of a quantitative design style.

  • Current literature assessing critical thinking is not very clear. The majority of the studies on critical thinking in relation to simulation assesses the student or faculty perception of a simulation scenario. Perception may not correlate with improved critical thinking, which would limit the reliability of the studies.

Literature review1

  • Sullivan-Mann, Perron, and Fellner(2009) clearly demonstrate an increase of knowledge through practice. It was the first of it’s kind to provide some quantitative data to the practical use of simulation in nursing education.

  • A recent study supports the use of simulation in preparation for clinical experiences in the real world. In this quantitative study, students have stated that they felt better prepared to solve problems after a simulation experience, when faced with a similar situation during traditional clinical setting (Bambini, Perkins, & Washburn, 2009). As the nursing student gains experience so should the confidence and clinical judgment.

Literature review2

  • Two additional studies (Lasater,2007; Alinier, Hunt, Gordon, & Harwood,2006) provided supportive evidence that the use of simulation technology is a means to enhance critical thinking by providing student the opportunity to practice in a safe, non-threatening environment.

  • Participated in one qualitative study by Panunto(2009) stated that simulation is a worthwhile teaching technique and adds a positive impact to learning. It also suggest that simulation be as realistic as possible to true patient care encounters.

Themes within the literature

  • In reviewing the literature, the majority of articles explored the relationship of confidence with that of simulation experiences. Several themes present themselves in the articles reviewed: critical thinking, student self-confidence, and satisfaction with simulation scenarios.

    • Self-confidence may in fact be just as important as the technical skills students acquire in nursing programs. The use of simulation allows students to practice patient care prior to performing on a actual patient. Several studies concluded that simulation will help build self confidence (Alfes, 2011; Rhodes, 2011; Smith & Roehrs, 2009).

Themes within the literature1

  • Student Satisfaction and self confidence was noted to have a positive relationship with the use of simulation. Both the study by Dougherty(2011) and Alfes(2011), examined and confirmed a positive correlation between simulation and student satisfaction.

  • Critical thinking, while many studies address this by anecdotal assessment, more quantitative research is needed. Of the studies review, Shinnick and Woo(2012) concluded that gains in knowledge using simulation does not produce changes in critical thinking. It was suggested that knowledge was gained simply by life experiences and not the use of simulation.

Research design

  • A purposed experimental research design will be utilized to assess the relationship of simulation-based learning to improve critical thinking. This design examines the cause and effect relationships among selected independent and dependent variables(Burns & Grove, 2009). This study design will utilize a pretest and posttest method.,


  • The possible limitations of this study is the small sample size, the limited diversity of participates and the possibility of instructor influence.

    • This study will have only 48 participates which may limit the generalizability of the study to other nursing programs. In addition to the small sample size, typically the nursing program in the study admits a large number of Caucasian women.

    • To decrease the likelihood of instructor influence a weekly course meeting will be conducted to ensure that both instructors are on the same page in regards to information given to the students during traditional clinical practice.


  • The sample will be a convenient sample of first year associate degree nursing students from a single school of nursing. Forty eight students will be divided into two groups. The control group, of 24 students will perform in the traditional clinical with real patient situations. The experimental group, of 24 students will participate in simulation scenarios for 10 days of the 30 days of clinical practicum. Addition to the 10 days of simulation the experimental group will continue with traditional clinical for the remaining 20 days of clinical.

Methods of data collection

  • All participates would have taken the HSRT pretest on enrollment to the nursing program. The scores will kept confidential and documented prior to simulation and clinical begins. The HSRT was chosen for the validity and reliability of the test.

  • Simulation will be conducted as scheduled along with traditional clinical participation.

  • Both the control and experimental group will participate in post conference (debriefing) at the completion of the clinical day.

  • At the conclusion of the clinical semester for both groups the HSRT posttest will again be given.

Data analysis procedures

  • A t-test for the pretest will be conducted to ensure that no participate had an unfair advantage. This will test for significant differences between the control and experimental groups.

  • ANOVA will be conducted to determine whether mean scores on the variables differ significantly from each other and whether the variables interact significantly with each other (Gall, Gall, & Borg, 2010).

Ethics and human relations

  • An application will be completed and approval to complete the study will be given by the college institutional review board.

  • During the clinical orientation, all students will be informed of the purpose, requirements, duration, and anticipated benefits of the study and will be asked to volunteer.

  • Students will sign a confidentiality statement to protect the rights and privacy of fellow students as well as the patients that they may encounter during clinical.

  • All student scores will remain confidential and be identified only by the student identification number.

  • If a increase in critical thinking among the experimental group is noted, all students will have the opportunity to participate in simulation scenarios.

Time line

  • Complete paperwork and submit to IRB

  • IRB approval

  • Presentation of research study to students obtain consents

  • Obtain the HSRT pretest results from registrar’s office (students should have take the HSRT prior to being admitted into the nursing program)

  • Divide students into experimental and control group and complete simulation scenarios

  • Administration of HSRT posttest to all participates

  • Analysis data and complete study


  • Alfes, C. M. (2011). Evaluating the use of simulation with beginning nursing students. Journal of Nursing Education, 50(2), 89-93. doi:10.3928/0148434-20101230-03

  • 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), 359-369. doi:10.1111/j.1365-2648.2006.03810.x

  • Bambini, D., Perkins, R., & Washburn, J. (2009). Outcomes of clinical simulation for novice nursing students: communication, confidence, clinical judgment. Nursing Education Perspectives, 79-82. Retrieved from


  • Benner, P. (1984). From novice to expert: excellence and power in clinical nursing practice. Upper Saddle River, NJ: Prentice Hall.

  • Burns, N., & Grove, S. K. (2009). The practice of nursing research: appraisal, synthesis, and generation of evidence (Sixth ed.). St Louis, Missouri: Saunders.

  • Dougherty, S. V. (2011). Simulation: Perceptions of first year associate degree nursing students (Doctoral dissertation). Houston: University of Houston, Texas.

  • Durham, C. F., & Alden, K. R. (2008). Enhancing patient safety in nursing education through patient simulation. In R. Hughes (Ed.), Patient Safety and Quality: An Evidence-based Handbook for Nurses (pp. 3-221 to 3-251). Rockville, Maryland: Agency for Healthcare Research and Quality.


  • Facione, N., & Facione, P. (2006). Health sciences reasoning test (HSRT): a test for critical thinking skills for health care professionals. Test Manual. Millbrae, CA: The California Academic Press LLC.

  • Gall, M., Gall, J. P., & Borg, W. R. (2010). Applying Educational Research (Sixth ed.). Boston: Pearson Education.

  • Lasater, K. (2007, June). High-fidelity simulation and the development of clinical judgment: students' experiences. Journal of Nursing Education, 46(6), 269-276. Retrieved from


  • Panunto, K. L. (2009). Simulation technology in nursing education: Student perceptions (Ed.D dissertation). Wilmington University, Delaware. Retrieved from http://www,

  • Rhodes, H. A. (2011). Simulation in Kansas practical nursing programs. Journal of Practical Nursing, 10-13. Retrieved from Retrieved from ERIC #927668188

  • Roehrs, C. J., & Smith, S. J. (2009). High-fidelity simulation: factors correlated with nursing student satisfaction and self-confidence. Nursing Education Perspectives, 74+. Retrieved from 12085


  • Shinnick, M., & Woo, M. A. (2012). The effect of human patient simulation on critical thinking and its predictors in prelicensure nursing students. Nurse Education Today, 129-155. doi:10.1016/j.nedt.2012.04.004

  • Sullivan-Mann, J., Perron, C. A., & Fellner, A. N. (2009). The effects of simulation on nursing students' critical thinking scores: A quantitative study. Newborn & Infant Nursing Reviews, 112-116. doi:10.1053/j.nainr.2009.03.006