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The Role of Simulation in. Nursing Education: A Regulatory Perspective. Suling Li, PhD, RN. National Council of State B...

The Role of Simulation in Nursing Education: A Regulatory Perspective Suling Li, PhD, RN National Council of State Boards of Nursing

Goals • •

Compare and contrast different types of simulation Identify potential advantages/disadvantages of simulation as a teaching strategy over actual clinical experience Discuss the use of simulation as an evaluation tool

Simulation • Simulation: – “… as a strategy – not a technology – to mirror, anticipate, or amplify real situations with guided experiences in a fully interactive way.”

• Simulator: – “…replicates a task environment with sufficient realism to serve a desired purpose”


The Role of Simulation • A teaching strategy • An evaluation tool

Trends in Nursing Education • Providing more experiential learning opportunity than instruction • Increased use of learning technology • More emphasis on outcome-based then process-based education • More evidence-based education strategies and curriculum

NCSBN Supports “…the inclusion of innovative teaching strategies that complement clinical experiences for entry into practice competency.” – NCSBN position paper on clinical education, 2005

Rationale • To ensure patient safety • To promote better preparation of new nurses • To support innovative teaching strategies • To overcome faculty and preceptor shortages and lack of clinical sites

Types Of Simulation • • • • • •

Screen-based/PC-based simulation Virtual patients Partial task trainers Human patient simulator Standardized patients Integrated models

Principles of Selecting Type of Simulation to Use • Should be driven by the educational goal/objective • Should match the level of the student • The higher the realism, the more effective it is in engaging the student

Strengths and Limitations of Different Types of Simulation

(Video) Revolutionizing Nursing Education: Patricia Thomas at TEDxUTA

1. PC-Based Simulation Strengths • Easy, flexible and unlimited access • Useful for knowledge acquisition and critical thinking • Accommodating to individual pace of learning • Good for lower/entry level students • Relatively low cost Limitations • No physical interactivity • Low fidelity • No experiential learning

2. Virtual Patient Simulation Strengths • Easy access • Economic for teaching multidisciplinary care • Accommodating to individual pace of learning • Good for lower level of students Limitations • Limited physical interactivity • Low fidelity • Limited experiential learning

3. Task Trainers Strengths • Low cost • Good for procedural practice Limitations • Low fidelity

4. Human Patient Simulation Strengths • High fidelity • Interactive experience • Animating theoretical knowledge within the context of clinical reality • Using emotional and sensory components of learning • Good for critical thinking, decision-making and delegation • Good for knowledge integration and higher levels of students Limitations • Costly • Limited access • Dependent on availability of human instructors/operators • Limited realistic human interactions

5. Standardized Patient (SP) Strengths • Higher realism in the interpersonal and emotional responses • Good for communication skills and interpersonal relationships training • Good for evaluation Limitations • Signs do not match symptoms • Inversed power dynamic

Principles should stay consistent but strategies flexible.

Factors Facilitating Teaching with High-Fidelity Simulation • • • • • • • • • •

Feedback Repetitive practice Curriculum integration Range of difficulty level Multiple learning strategies Capture clinical variation Controlled environment Individualized learning Defined outcomes or benchmarks Simulator validity

Issenberg et al, 2005

Simulation Fidelity • The physical, contextual, and emotional realism that allows persons to experience a simulation as if they were operating in an actual healthcare activity. - 2007 SSH summit

A Question for Regulation • What is the role of simulation in nursing education in relation to clinical education?

Potential Advantages of Simulation Over Actual Clinical Experience • Reduces training variability and increases standardization • Guarantees experience for every students • Can be customized for individualized learning • Is more accurate reflective learning especially with HPS • Is student-centered learning • Allows independent critical-thinking and decision-making, and delegation • Allows Immediate feedback

Potential Advantages of Simulation Over Actual Clinical Experience (cont.) • Offers opportunity to practice rare and critical events • Can be designed and manipulated • Allows calibration and update • Can be reproduced • Occurs on schedule • Offers opportunities to make and learn from mistakes • Is safe and respectful for patients • Allows deliberative practice • Also uses the concept of experiential learning

“ Tell me, and I will forget. Show me, and I may remember. Involve me, and I will understand.” - Confucius, 450 BC

Limitations of Simulation Compared to Actual Clinical Experience • • • •

Not real Limited realistic human interaction Students may not take it seriously No/incomplete physiological symptoms

(Video) About NCSBN: An Introduction to National Council of State Boards of Nursing

Vision for the Future: Continuum of Learning Class → Simulation → Clinical→ Real world • Integrated into mainstream healthcare education

Simulation as a Teaching Strategy: Challenges • • • •

Initial capital expenditures High financial cost Faculty development Ongoing faculty/administrative/technical support

Research on Simulation: Kirkpatrick Criteria (1998)

• • • •

Reaction Learning Behavior Results

Future Research: Simulation as a teaching strategy • Impact on competence • Impact on patient care

NCSBN’s Research Initiative on Simulation • Goal: To explore the role of high fidelity simulation in basic nursing education in relation to real clinical experience

The Question • Can high fidelity simulation experience be counted as real bed-side clinical experience?

Specific Objective • Compare and contrast the effects of simulation alone and in combination with clinical experience on knowledge acquisition/retention, self-confidence, and clinical performance

Design • A randomized controlled study with repeated measures pre- and postsimulation/clinical to compare the effect of simulation alone and in combination with clinical on knowledge acquisition/retention, self-confidence, and clinical performance.

Figure 1. Study Scheme Front-load didactic instruction

Baseline assessment


Simulation alone


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Clinical alone

Outcome measures

1. Knowledge acquisition/retention 2. Self-confidence 3. Clinical performance via standardized patient

Groups 1. Simulation without clinical (30 hours of simulation) 2. Simulation + clinical (15 hours of simulation and 15 hours of clinical) 3. Clinical without simulation (30 hrs of clinical)

Outcome Measures • Knowledge acquisition/retention • Confidence • Clinical performance

Knowledge acquisition/retention • Assessed with written examinations before (after didactic instruction, which is frontloaded) and after clinical/simulation experiences. • The examinations were equivalent in content.

Confidence • Assessed with a Likert-type selfconfidence scale which consisted of 12 items. • Reflect the student’s confidence in assessing, intervening and evaluating pts with critical illness.

Performance Evaluation with SPs • • • •

Three stations Each station provided one scenario 10-15 min each scenario Focused on symptom recognition, assessment and intervention • Performance evaluated by a faculty member on-site and videotaped for further analysis by two additional faculty members • Staff: 6 faculty and 6 SPs

Format • • • • •

All students enrolled in the course Occur over 2 days Rush CON labs Each student – 3 scenarios using SPs One hour commitment for each students

Each Station • • • •

Has the chart outside the pt room The chart has info on pt hx, meds etc Each pt room has essential equipment Faculty member acts as evaluator and MDs if needed

Three Scenarios • A pt with CP (hx of knee replacement) • A pt with sudden onset of SOB (hx of abdominal surgery) • A pt with a change of LOC (hx of fall at night)

A Survey of Boards of Nursing Nehring, 2006 • Purpose: examine the status of regulation changes concerning the use of simulation in nursing programs and if no regulation changes, the presence of approval for use of simulation • 44 states plus the District of Columbia, and Puerto Rico participated

A Survey of Boards of Nursing (cont.) • Five states and Puerto Rico have changed nursing regulations to allow a percentage of clinical time with the simulators (Nehring, 2006) • One state specified a percentage of 10% of clinical time to be replaced by simulation experience (Nehring, 2006)

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A Survey of Boards of Nursing (cont.) • While no changes in regulation, 16 states give permission for schools to use a percentage of their clinical time with the simulation experience (Nehring, 2006) • The percentage is determined on a case-by-case basis (Nehring, 2006)

The Role of Simulation • A teaching strategy

• A competence assessment tool

Competency Assessment: Miller’s Pyramid (1990) Does Shows how Knows how Knows

Common Assessment Methods • Written exam (MCQ) • Checklist evaluation • Portfolios/Record review (e.g., skill’s checklist) • Simulations (Standardized patients and models)

Common Assessment Model with Simulation Checklist Global rating

Process measure


Global rating

Outcome measure

Combined Criteria

Types of Simulation Models for Competency Assessment • OSCE • Computer-based simulation • Computerized mannequin

Potential Advantages of Using Simulation for Assessment • Able to measure more than knowledge level • Performance-based • Standardized (same conditions for all test takers) • Measures integrated KSA

Challenges of Using Simulation as an Assessment Tool • Measurement issues – Reliability – Validity • Cost • Feasibility

Future Research: Simulation as an Assessment Tool • Establish valid content, structure and scoring metrics • Cost-effectiveness compared to other tools

The Future Integrated models for both teaching and assessment using simulation Setting standards and guidelines for various kinds of learning and assessment


Contact Information Suling Li, PhD, RN Tel: 312.525.3658 Email: [emailprotected]


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