Applying Integrative Learning Strategies and Complexity Theory to Design Simulations for Care of Complex Patients

Dunn, Karen S. PhD, RN, FGSA; Riley-Doucet, Cheryl K. PhD, RN, FGSA

doi: 10.1097/NNE.0000000000000312
Feature Articles

Nurse educators use a variety of clinical simulation strategies to promote cognitive, psychomotor, and affective learning. Statistically significant increases in self-confidence levels were found among senior-level nursing students in the assessment and management of medical and psychiatric symptoms after participating in strategically designed, complex, student-led clinical simulations. Having students role play simulation scenarios that are developed from real-life clinical experiences is a cost-effective interactive strategy that enhances their communication and technical skills.

Author Affiliations: Associate Professor (Dr Dunn) and Professor (Dr Riley-Doucet), School of Nursing, Oakland University, Rochester, Michigan.

This study was funded by Center of Teaching and Learning, Oakland University.

The authors declare no conflicts of interest.

Correspondence: Dr Dunn, School of Nursing, Oakland University, 3041 Human Health Bldg, Rochester, MI 48309 (

Accepted for publication: June 25, 2016

Published ahead of print: August 12, 2016

Article Outline

With the rapid growth of the aging population, nurses need to be able to manage older adult patients with complex, chronic medical conditions. The confluence of normal age-related changes, comorbidities, cognitive impairments, and altered responses to pharmacological and other medical treatments increase the vulnerability of this population.1 According to Wilson,2 human beings have complex biological and social systems that are compromised when illness occurs, causing unpredictable patterns of behavior that challenge health care providers and require a wide array of interventions. Based on Wilson’s complexity theory, patients hospitalized for medical problems with preexisting conditions are at a greater risk for adverse outcomes from any procedure than well persons are, which can add to the complexity and unpredictability of their situation. To integrate complexity theory into curriculum development, students would have to engage in complex, clinical experiences with uncertain and unfamiliar contexts to enable them to develop new competencies and behaviors for patient care.

Limitations in clinical placements and strict hospital policies to ensure patient safety, however, have prevented students from developing therapeutic communication and technical skills that are needed to address patients with complex comorbidities (eg, motivational interviewing and administering opioids via intravenous push and psychotropic medications). To address this limitation, nurse educators use a variety of effective, clinical simulation strategies (high-fidelity manikins, case studies, and improvisational actors) to promote cognitive, psychomotor, and affective learning within safe environments.3-6 These simulation strategies aim to reflect real-life scenarios yet may still lack the authenticity of human-to-human interactions and the reciprocal relationships between comorbid medical and mental health conditions.

Therefore, the purpose of this study was to examine whether the use of strategically designed, complex, student-led simulation scenarios would foster student self-confidence in the assessment and management of care of patients with comorbid, chronic mental and physical illnesses that commonly occur within adult and older adult populations. Simulation scenarios developed in this study were role played by the students, which enabled them to verbalize therapeutic communication skills and practice technical skills in the nurse role and use their knowledge of physical and mental health symptoms to portray a patient with these comorbidities. The student-led simulation scenarios were also evaluated to determine if the participants perceived them to be an effective and important simulation learning experience.

To ensure that the simulations reflected higher levels of clinical complexity, an “integrative learning” approach was used to develop the student-led simulation scenarios. Integrative learning approaches assist students to achieve more comprehensive understandings of complex situations through the synthesis of divergent perspectives and experiences.7 In this simulation study, objectives from 2 clinical courses, mental health nursing and medical-surgical nursing, were strategically integrated into the design and development of the simulation scenarios. All of the scenarios included a patient who role played mental and physical health symptoms and a nurse who role played motivational interviewing communication skills while executing the nursing process. Six scenarios were developed by the faculty teaching the 2 didactic courses, which focused on specific content covered in class. These scenarios were then validated by 8 mental health clinical faculty and 8 medical-surgical clinical faculty who facilitated the implementation of this study.

The 6 scenarios included (1) postoperative older adult patient with dementia (focus is on assessment of pain), (2) older adult admitted for heart failure experiencing anxiety, (3) older adult with Parkinson’s disease and depression, (4) older adult with pneumonia and delirium, (5) adult with schizophrenia and undiagnosed diabetes, and (6) a dysfunctional older adult family dyad that included a wife with known type 2 diabetes experiencing mild cognitive impairment and husband who demonstrated no insight into the complexity of the wife’s comorbid conditions.

Back to Top | Article Outline


Setting and Participants

A convenience sample of 194 senior-level nursing students in a bachelor of science in nursing program in the Midwest United States consented to participate in this study. Students were asked to participate if they were currently enrolled in both medical-surgical and mental health clinical rotations. The simulations were run at the end of the academic semester, when all of the students completed the didactic coursework in both medical-surgical and mental health courses. Most were female (n = 164, 86.3%) and white (n = 158, 83.2%), with a mean (SD) age of 25.5 (6.35) years (range, 20-54 years).

Back to Top | Article Outline

Theoretical Framework

The theory for designing, implementing, and evaluating the complex, student-led simulations was based on the Jeffries8 model. There are 5 major components to this theory: teacher, student, educational practices, design characteristics and simulation, and outcomes. Teachers in this study were the student’s clinical faculty who attended a workshop to prepare for the simulations and acted as facilitators providing learner support and debriefing. Educational practices included (1) actions that required active participation, (2) feedback on student performance and the simulation experience, and (3) collaborative learning. All of the 5 specific areas in Jeffries simulation theory (objectives, planning, fidelity, complexity, cues, and debriefing) were addressed when the simulations were designed.

Back to Top | Article Outline

Learning Outcomes

The last major component in the Jeffries8 simulation theory is learning outcomes. The first learning outcomes were achieved through the skill performance of the student role playing the nurse. One assumption of this study was that learning would be enhanced as the students practiced role playing the nurse using scripted scenarios. All of the scripted scenarios included (1) using verbal and technical assessment skills, (2) administration of various types of medications (eg, oral, intravenous, intravenous piggyback, and intravenous push), (3) performing safety checks, (4) using motivational interviewing techniques, and (5) providing compassionate care. Skill performance checklists were developed for each of the scripted scenarios and included all of the assessment data obtained from the nurse, mental health and medical-surgical conditions being role played by the patient, mental health and medical-surgical priority diagnoses, and interventions role played by the nurse. These checklists were used by the clinical faculty during the practice sessions to make sure all of the scripted lines, symptoms, and technical skills were role played accurately. Clinical faculty also used the checklists as guides during the debriefing sessions where discussions about what the students observed and recorded on the participant observations sheets matched what was planned in each scenario In addition, these checklists were used in the coding of the participant observation sheets for data entry.

Students who role played patients also were expected to get a better understanding of the mental and physical health symptoms of the conditions that they were prompted to portray. Students role played the mental and medical symptoms through observable behaviors or dialogue. Another assumption of this study was that by integrating symptoms of both conditions, the students would be able to synthesize the complexity and importance of addressing both co-morbid conditions.

Clinical reasoning was another learning outcome that was measured through the completion of a participant observation sheet filled out by each student who watched the simulation scenarios. Students observing the scenarios were prompted to (1) identify pertinent assessment data role played by the nurse, (2) identify both medical-surgical and mental health conditions role played by the patient, (3) write a complete medical-surgical and mental health priority nursing diagnoses, and (4) identify nursing interventions that were role played by the nurse. Completed participant observation sheets were coded for each simulation scenario based on the number of correct observations outlined on the skill performance checklists. Students also completed a qualitative item asking what could have improved each scenario.

Back to Top | Article Outline

Student Confidence Levels

Student clinical confidence levels were measured before and after all of the simulations were role played and observed in both mental health and medical surgical nursing using the Mental Health Nursing Clinical Confidence Scale (Mental Health NCCS)9 and the Medical/Surgical Nursing Clinical Confidence Scale (Med/Surg NCCS). The Mental Health NCCS is a 20-item scale that covers 6 domains: assessment, communication, education, medication knowledge, self-management, and teamwork. Responses for this scale are measured on a 4-point scale from 1 (not at all confident) to 4 (completely confident). Higher scores are indicative of higher levels of confidence. Two items from the Mental Health NCCS were removed from the scale because they reflected working with teams, which were not an objective of these scenarios, reducing the scale to 18 items with a range of 18 to 72. In a sample of 339 undergraduate nursing students, test retest reliability for the Mental Health NCCS was conducted, resulting in a correlation of 0.86 and corresponding Cronbach’s α of .92.9

After an extensive review of the literature, no similar scale was found that measured student clinical confidence levels in medical-surgical nursing. Therefore, permission was obtained from Dr Bell to use and make adaptations to the Mental Health NCCS that would measure the student’s clinical confidence levels in medical-surgical nursing. Thirteen items from the original scale were modified to reflect student confidence levels in medical-surgical assessment, communication, education, medication knowledge, and self-management, and 7 were removed, yielding a total score range of 13 to 52. Validation of the Med/Surg NCCS was done before initiation of the study by a panel of 8 expert medical-surgical clinical faculty who reviewed the simulation scenarios and participated as facilitators in this study.

Back to Top | Article Outline

Simulation Effectiveness

The Student Perception of Effective Teaching in Clinical Simulation Scale (SPETCSS)10 measured the student’s perceptions of the effectiveness and importance of the student-led simulations. Permission to use the SPETCSS was obtained from the author. The SPETCSS is a 33-item scale with 2 response scales that measure the extent of how the students agree (strongly disagree to strongly agree) with each item statement and also the importance of each item statement (not important to extremely important) on a 5-point Likert scale. The extent response scale measured the participants’ perceptions of the helpfulness of clinical faculty and the use of simulation as an effective teaching strategy. The importance response scale measured the student’s perceptions of the degree of importance of using these simulation teaching strategies to achieve the learning outcomes. Higher numbers for both scales reflect positive responses and ranged from 33 to 165. A SPETCSS content validity index of 0.91 was computed from a panel of 7 simulation experts. In a sample of 121 undergraduate nursing students, internal consistency reliability scores for the extent response scale was α = .95 and α = .96 for the importance scale.10

Back to Top | Article Outline


After university institutional review board approval was obtained, nursing students who were currently enrolled in senior-level mental health and medical-surgical clinical courses were recruited for this study. Students were given an information sheet outlining the study and written consent was obtained. All participants met in a large classroom and were given an index card with an ID number on it, as well as the pretest that included a demographic survey, the Mental Health NCCS, and the Med/Surg NCCS to fill out. Students were asked to put this ID number on their pretest and to save this ID number for their posttest. Students were then assigned to their own clinical faculty member (mental health or medical-surgical) or assigned to another clinical faculty member to form groups of 8 or 9 students (1 scenario added a family member).

Each clinical group faculty member was then given 4 different student-led clinical scenarios hidden within a sealed envelope that had 1, 2, 3, or 4 printed on the outside. The clinical faculty member was then prompted to divide the group into 4 dyads or 3 dyads and 1 triad, and each was given a sealed envelope with the scenario that the students were responsible to role play. One student role played the nurse, and the other student role played the patient and in 1 scenario, a family member. Students were counseled not to open these envelopes until they were escorted into a designated simulation room (the same number as the envelope). Once each dyad/triad was formed and given their envelopes, the clinical faculty members escorted them into 1 of 4 simulation rooms designated for each scenario. Envelopes were then opened, and the students were given time to read the scripted simulation scenarios.

With the help of the clinical faculty members, students practiced their roles based on the scripted scenario. The clinical faculty members also had the Skill performance checklists to ensure that the important dialogue, symptoms, and interventions were portrayed. It took approximately 45 minutes for all of the students to practice, and they were then escorted back to their originally assigned clinical group where again they were counseled not to talk about their scenarios to each other. Each clinical group then rotated through each of the 4 simulation rooms where each dyad/triad role played their student-led scenario while the other students in their clinical group observed. Students observing were prompted to write down pertinent assessment data and interventions they observed in the scenario on a participant observation sheet. When the student-led simulation was completed, only the students observing could then discuss the scenario and formulate the priority nursing medical-surgical and mental health diagnoses for that scenario.

Once the students were satisfied with their recorded observations, the sheets were collected by the clinical faculty members and debriefing began. Debriefing discussions included identification of all the pertinent assessment data, the mental health and medical-surgical conditions, the priority diagnoses, and interventions recorded on the skill performance checklists. Students were prompted to discuss why they chose the answers that they formulated if they were not the same as outlined on the checklists and what could have been done to improve the scenarios. When all clinical groups had rotated through the 4 scenarios, they were escorted back to the large classroom and given the posttest that included the Mental Health NCCS, Med/Surg NCCS, and SPETCSS. Total time for this study was approximately 4 hours.

Back to Top | Article Outline

Data Analyses

Data were analyzed using SPSS 18.0 computer software,11 and the level of significance for each test was preset at .05. Analyses for this study included descriptive statistics of the sample and measurement tools, paired t tests to determine significant differences between pretest and posttest scores and reliability analyses of the measurement tools. To ensure a medium effect size (0.5) using a 2-tailed paired t test (α = .05) at an 80% power to detect a significant difference, a minimum of 128 participants would have to be recruited.

Back to Top | Article Outline



Of 198 senior-level nursing students, 194 consented to participate in the study. Because this simulation was a course requirement, the 4 students who opted not to be included in the study still had to participate in the simulations; however, their documentations were not included in the findings.

Back to Top | Article Outline

Student Self-confidence Levels

Statistically significant increases in student self-confidence levels were found in both medical-surgical (t = −1.74, df = 193, P < .01) and mental health (t = −14.12, df = 193, P < .01) competencies after simulation. Post hoc analyses using t tests revealed that all items on both Mental Health NCCS and Med/Surg NCCS had significant increases from pretest to posttest. Students reported having more self-confidence in communication skills, assessment skills, medication knowledge, and ability to educate patients with certain medical-surgical and mental health conditions. Both Mental Health NCCS (pretest α = .90, posttest α = .93) and Med/Surg NCCS (pretest α = .91, posttest α = .94) yielded excellent reliability.

Back to Top | Article Outline

Participant Observations and Clinical Reasoning

The participant observation sheets revealed important findings related to clinical reasoning and students’ abilities to identify important assessment data, distinguish mental health and medical-surgical conditions through symptom recognition, formulate what was the mental health and medical-surgical priority diagnoses, and note the interventions performed by the nurse. Correct responses on each sheet were summed for each of the 4 topical areas and average scores were computed (Table). On average, most of the students were able to successfully identify about half of the important assessment data and interventions. Of particular interest, however, was that many students inaccurately reported the use of assessment tools to gather data as an intervention. For example, many of the students reported that the nurse used the Mini-Mental Examination as an intervention and not as a means for collecting assessment data. Another interesting finding was that most of the students were able to distinguish what the mental health and medical-surgical conditions were yet were unable to formulate the priority diagnoses for each condition. Students also lost points if the conditions they reported were incomplete, for example, reporting diabetes instead of type 2 diabetes or cognitive impairment instead of mild cognitive impairment. After the first use of the simulation scenarios, we modified the participant observation sheet to include prompts for identifying priority diagnoses.

Back to Top | Article Outline

Student Perception of Effective Teaching in Clinical Simulation

Overall, the participants perceived these strategically designed, complex, student-led simulations to be an important and positive learning experience. Mean scores for each item reflected that most of the participants were in agreement that the simulation was an effective learning strategy. The lowest item mean, however, suggested that the participants were neutral with their perception of the organization of the simulation experience (mean [SD], 3.44 [1.35]). This finding was not surprising because of the pilot nature of the study and large number of students who participated. After each session, the research team along with the clinical faculty identified areas of concern and addressed them to improve the overall organization of each consecutive simulation experience. Post hoc analysis of the mean scores of the students’ perception of the organization of the simulation experience between the first (mean [SD], 3.20 [1.43]) and second (mean [SD], 3.75 [1.17]) semester groups revealed a statistically significant difference between them (t = −2.85, df = 189, P < .01). Reliability analyses for both the extent (α = .97) and importance (α = .97) response scales were excellent.

Back to Top | Article Outline


Allowing nursing students to role play the simulations in this study was found to be an effective, interactive teaching strategy that provided them a safe and informative opportunity to practice communication and technical skills. Similar findings were recently reported with the use of improvisational actors6 who role played a complex simulation involving an older adult with heart failure and dementia experiencing delirium. The use of improvisational actors, however, can be very costly and require added preparation time. In our study, the nursing students became the actors, eliminating the cost of hiring actors and the time required to train them. Students were also given an opportunity to be a part of an integrative learning experience that increased their confidence in addressing comorbid mental health and medical-surgical conditions. Students completing the participant observation sheets used the knowledge that they gained from both didactic courses and clinical reasoning to complete them. Although most students were able to capture approximately half of the assessment data, priority diagnoses, and interventions, debriefing sessions provided clinical faculty time to discuss the experience with their students and the rationale for their clinical reasoning decisions. Data from the participant observation sheets also identified that students at the senior level were still having difficulty distinguishing assessment from interventions within the nursing process. As nurse educators, we felt the impact of this finding was important in terms of evaluating the curriculum, and we reported the finding to the faculty assembly to improve program outcomes.

Another strategy used in this study was concealing the scenarios in envelopes. This prevented the students from talking to each other and revealing the important highlights of each scenario. Having a number of scenarios to choose from and changing them across semesters was helpful because it prevented the students from talking about the scenarios to the following cohort. This was a lesson learned from nurse educators who reported the importance of keeping simulations evolving with multiple outcomes.12

Back to Top | Article Outline


One limitation of this study was that it was conducted at only 1 institution, minimizing the generalizability of the study findings. Another limitation, identified from comments written on the participant observation sheet by the first group of students, related to the authenticity of the student-led simulation owing to poor role playing of the clinical symptoms. These student comments support previous literature that reported authenticity as a major limitation of clinical simulation.5,13 Difficulty in realism using standardized patients when portraying actual representations of the signs and symptoms have been reported14; however, no significant differences have been found between the use of standardized patients (individuals trained to present an illness) and high-fidelity simulators15 in nursing education.

To address this study limitation, the principal investigators developed another training session with the clinical faculty to ensure adherence to the scripted scenarios and to emphasize that the symptoms outlined in the scenarios were similarly role played by the students. In addition, both mental health and medical surgical clinical faculty were present during each practice session to confirm that all comorbid symptoms were accurately enacted while role playing the scenarios. Further research is needed to better understand how to achieve fidelity and/or authenticity to improve the effectiveness of simulation in nursing education.

Back to Top | Article Outline


Nurse educators use a wide array of various simulation types that may include very simplistic case study vignettes to high-fidelity simulators. Purchasing high-fidelity simulators or improvisational actors, however, is costly. Having students role play simulation scenarios that are developed from real-life clinical experiences is a cost-effective interactive strategy that enhances their communication and technical skills. In addition, the use of a participant observation sheet can be an effective tool in the evaluation of student competencies in clinical reasoning and the application of the nursing process.

Back to Top | Article Outline


1. Miller C. Nursing Wellness in Older Adults. 7th ed. Alphen aan den Rijn, the Netherlands: Wolters Kluwer; 2014.
2. Wilson M. Complexity theory. Whitireia Nurs J. 2009;16(1):18–24.
3. Nursing shortage. American Association of Colleges of Nursing Web site. Available at Published 2015. Accessed December 15, 2015.
4. Stroup C. Simulation usage in nursing fundamentals: integrative literature review. Clin Simul Nurs. 2014;10(3):e155–e164.
5. Dunn KS. Simulation: general. In: Smith MJ, Carpenter R, Fitzpatrick JJ, eds. Encyclopedia of Nursing Education. New York: Springer Publishing; 2015:331–333.
6. Paquette M, Bull M, Wilson S, Dreyfus L. A complex elder care simulation using improvisational actors. Nurse Educ. 2010;35(6):254–258.
7. Newell WH. Educating for a complex world: integrative learning and interdisciplinary studies. Liberal Educ. 2010;96(4):6–11.
8. Jeffries PR. A framework for designing, implementing, and evaluating simulations used as teaching strategies in nursing. Nurs Educ Perspect. 2005;26(2):96–103.
9. Bell A, Horsfall J, Goodin W. The Mental Health Nursing Clinical Confidence Scale: a tool for measuring undergraduate learning on mental health clinical placements. Aust N Z J Ment Health Nurs. 1998;7(4):184–190.
10. Reese CE. Effective teaching in clinical simulation: development of the Student Perception of Effective Teaching in Clinical Simulation Scale [dissertation]. Indianapolis, IN: Indiana University–Purdue University at Indianapolis; 2009.
11. IBM SPSS. SPSS Faculty Pack for Windows (Version 18.0) [computer software]. Chicago, IL: SPSS Inc; 2010
12. Ridley RT. Simulation: rehearsing lines or clinical reasoning. Nurse Educ. 2015;40(3):111–112.
13. Bland AJ, Topping A, Tobbell J. Time to unravel the conceptual confusion of authenticity and fidelity and their contribution to learning within simulation-based nurse education: a discussion paper. Nurse Educ Today. 2014;34(7):1112–1118.
14. Kowitlawakul Y, Chow YL, Salam ZHA, Ignacio J. Exploring the use of standardized patients for simulation-based learning in preparing advanced practice nurses. Nurse Educ Today. 2015;35(7):894–899.
15. Ignacio J, Dolmans D, Scherpbier A, Rethans J, Chan S, Liaw SY. Comparison of standardized patients with high-fidelity simulators for managing stress and improving performance in clinical deterioration: a mixed method study. Nurse Educ today. 2015;35(12):1161–1168.

integrative learning; medical surgical and mental health nursing; nursing students; role playing; self-confidence; simulation

Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved