Center conducting review:
University of Newcastle JBI Evidence Synthesis Group: University of Newcastle Evidence Based Health Care Group
Undergraduate nursing education is similar to most health disciplines in that students require supervised opportunities to apply knowledge and skills obtained through teaching and learning experiences into clinical practice. Some of the challenges that directly impact the quality of students' clinical experiences include inadequate quantity and variable quality of clinical placements; patients with shorter hospital stays and higher acuity; and the unpredictability of crisis situations 1. There is no guarantee that clinical placements will provide appropriate learning opportunities for all students to experience low incidence but high risk clinical events that prepare them for safe and effective clinical practice. This is directly reflected by new registered nurses who do not meet expectations for entry level clinical judgment ability as indicated by inability to recognising the ‘deteriorating patient’ 2. Nursing schools are therefore challenged to find innovative, cost-effective and efficient teaching and learning strategies for students to learn the skills necessary for safe practice.
To address some of these issues, human patient simulation manikins (HPSMs) are increasingly being adopted as teaching and learning strategies in undergraduate nursing education. This interest was fuelled in part by the Institute of Medicine Report (2000) 3 that encouraged the use of simulation and related technologies as strategies to improve patient safety. High fidelity HPSMs are life-sized, computerised models with realistic anatomical structures and high response fidelity4. With advances in technology, HPSMs can be programmed to mimic diverse parameters of human anatomy and physiology. For example, changes in cardiovascular, pulmonary, and neurological systems can be simulated with the ability to respond to nursing and pharmacological interventions in real time 5-8. As a result of their high fidelity response, they can be used to simulate a diverse range of scenarios that students are likely to encounter in clinical practice. Examples of
HPSMs include Laerdal SimMan Universal Patient Simulator (SimMan-G3TM) and METITM manikins.
Internationally, five states within the United States as well as the territory of Puerto Rico have enacted regulatory changes to allow hours spent with HPSMs to replace some clinical placement hours 9. Similarly, in the United Kingdom, the Nursing and Midwifery Council Simulation and Practice Learning Project 10, recommended that up to 300 hours of simulated practice learning hours be counted toward the direct care hours required to complete the nursing program. The increasingly adaptation of simulation technologies warrants clarification of the basic assumptions underlying the integration of HPSMs in nursing education.
For the purposes of this systematic review, appropriateness refers to the best conditions under which HPSMs can be integrated into undergraduate nursing education. In undergraduate nursing education HPSMs have been utilised in different ways. Examples include: as an adjunct to traditional clinical nursing education 9, 11, 12; as a substitute for actual clinical experience 13; as remedial learning for students who encounter difficulties in the clinical setting 14 and to assess specific clinical skills. The literature shows that this ‘piecemeal’ integration of HPSMs in undergraduate nursing education indicates a lack of cohesive pedagogy for the best ways to integrate HPSMs in nursing education. This situation makes it difficult to determine the meaningfulness and appropriateness of using HPSMs as a teaching and learning strategy in undergraduate nursing education.
Kardong-Edgren, Starkweather, and Ward 15 observed that, in most cases, it is much easier to purchase the HPSMs than to effectively integrate them into the curriculum as tools for consistent teaching and active learning. Other studies confirm the underutilisation of HPSMs in education with such investments sometimes turning into little more than expensive ‘dead weights’ in simulation laboratories16, 17. Rhodes and Curran (2005)11, for example, argue that for optimum results, all HPSMs sessions must have pre-simulation orientation to the scenario prior to a scenario followed by a twenty-minute scenario and twenty minute debriefing, with videotape review. Although it has a medical education focus, the Best Evidence Medical Education Collaboration systematic review of high-fidelity simulation characteristics and uses in medical education identified appropriate curriculum integration as one of the key features required to achieve effective learning 18. This is consistent with the available literature suggesting that simulation is most successful when implemented across a curriculum 19, 20. For documentation of best practices in undergraduate nursing education, more investigation into the best way to integrate HPSMs in nursing curricula is required.
Jeffries (2005)19 attempted to address this gap by providing a model for integrating simulation in nursing education. The proposed simulation models has five major components namely: teacher; student; educational practices; design characteristics and simulation; and outcomes19. Her model has become seminal work and offers key pedagogical features for implementing and evaluating simulation programs. However, it is not clear if replicable, scientific, transparent and exhaustive methods were used to identify theoretical and empirical literature that forms the basis of this model. Such a methodological shortcoming can potentially lead to biased results and conclusions 21.
For the purpose of this review meaningfulness relates to the personal experiences and opinions of undergraduate students and academics regarding the use of HPSMs as a teaching and learning strategy. A recent systematic review by Lapkin et al.22 explored effectiveness of using human patient simulation manikins in the teaching of clinical reasoning skills to undergraduate nursing students. This systematic review reported that the use of human patient simulation manikins significantly improves knowledge acquisition, critical thinking and ability to identify deteriorating patients 22. The results of this systematic review also demonstrated high self-reported levels of learner satisfaction with human patient simulation manikins. However, this requires further exploration from a qualitative perspective to gain a broader perspective as that systematic review only considered quantitative studies. It is equally important to gauge students' and academic perspectives of HPSMs so as to develop appropriate evidence based recommendations for undergraduate nursing educators. Learner and academics satisfaction is important as it may potentially enhance engagement thereby facilitating learning.
A study by Feingold and colleagues (2004) 23 evaluated the personal experiences and opinions of undergraduate students and academics regarding the use of a
Laerdal SimMan Universal Patient Simulator (SimMan) in a simulated clinical scenario. Undergraduate nursing students used the SimMan in clinical simulation activities during two consecutive semesters. Students were surveyed using a 20-item tool scored on a 4-point Likert scale while four academic members were surveyed using a 17-item tool with the same response scale. Survey response analysis using descriptive statistics indicated that the majority of both student participants and academics identified the use of SimMan as a realistic and valuable teaching and learning methodology 23. The authors however report that although 100% of the academic members believed that skills learned with the HPSM would transfer to real clinical settings, approximately half of the students did not agree23.
Such a dichotomy in results indicates the need to further exploration of the use of HPSM in undergraduate nursing education.
Despite the fact that millions of dollars are being invested in HPSMs and that some nursing regulatory authorities accredit simulation hours, there is no unequivocal evidence regarding the meaningfulness and appropriateness for the use of this technology in undergraduate nursing education. The basic assumption underlying the use of HPSMs is that patient safety, learning from mistakes and managing errors in simulated environments can improve clinical and diagnostic skills in a way that is transferable to practice24, 25. A search of Cochrane and Joanna Briggs Institute databases indicates that no systematic review exists or is currently underway to explore the meaningfulness and or appropriateness of using human patient simulation manikins in undergraduate nursing education. Considering the rationales discussed above and identified gaps in the literature, it is appropriate that a systematic literature review is conducted in order to appraise and synthesise the best available evidence on the meaningfulness and appropriateness of integrating human patient simulation manikins (HPSMs) into undergraduate nursing education. This review will provide insights into those factors that need to be given priority when integrating HPSM in undergraduate nursing education.
The aim of this review is to identify the best available evidence on the meaningfulness and appropriateness of integrating human patient simulation manikins (HPSMs) into undergraduate nursing education.
This review will systematically examine the evidence to answer the following questions:
- What are the perspectives and experiences of students and academics on the appropriateness and meaningfulness of the use of HPSMs in undergraduate nursing education?
- What teaching and learning practices with HPSM are considered appropriate and meaningful by students and academics?
Types of participants
The review will consider studies that include undergraduate nursing students and academics who are involved in undergraduate education. Studies that consider other allied health care professionals will be excluded unless data for undergraduate nursing students are included and analysed separately.
Types of intervention(s)/phenomena of interest
The review will consider as phenomena of interest the experiences, values, opinions, beliefs and interpretations of undergraduate nursing students and academics using HPSM for teaching and learning purposes.
Types of studies
This review will consider qualitative research studies that draw on the experiences of undergraduate nursing students and academics on the use of HPSMs. In the absence of research studies, textual evidence such as opinion papers will be considered for inclusion.
The search strategy aims to find both published and unpublished studies, limited to the English language and restricted to the last ten years. A three-step search strategy will be utilised in each component of this review. Initially a limited scoping search of MEDLINE and ProQuest nursing journals will be undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe each article retrieved. Initial search terms to be used are: students, nursing; nurs*; simulat*;human patient simulator; manikin teaching and training.
The second step will involve searching electronic databases using several combinations of key words and index terms identified by the initial literature scoping. Where appropriate, key words will be exploded and truncated.
Using a defined search and retrieval method, the databases to be searched are:
- Cochrane Database
- ProQuest Nursing Journals
For grey literature we will search:
- Directory of open access journals
- Networked digital library of theses
- Conference Proceedings
The third stage involves the hand searching of all identified reports and articles to find any additional articles:
The bibliographical software package EndNoteTM will be utilised to manage all references as it facilitates the importation of references from electronic databases as well as the linkage of references into the Joanna Briggs Institute (JBI)-Comprehensive Review Management System (CReMSTM) for assessment of methodological quality using the JBI critical appraisal tools. These guidelines have been developed to minimise bias and establish validity of the findings.
Assessment of methodological quality
Papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using the standardised critical appraisal instruments from the JBI Qualitative Assessment and Review Instrument (JBI-QARI) or Narrative, Opinion and Text Assessment and Review Instrument JBI-NOTARI (for text and opinion papers)(Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion with a third reviewer.
The qualitative data will be extracted from papers included in the review using the standardised data extraction tool from the JBI-QARI (Appendix II). The opinion and other text data will be extracted from papers included in the review using the standardised data extraction tool from the JBI-NOTARI (Appendix II).
Where meta-synthesis is possible, qualitative research findings will be pooled using the JBI-QARI. This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings (Level 1 findings) rated according to their quality, and categorising these findings on the basis of similarity in meaning (Level 2 findings). These categories are then subjected to a meta-aggregation in order to produce a single comprehensive set of synthesised findings (Level 3 findings) that can be used as a basis for evidencebased practice. Where textual pooling is not possible the findings will be presented in narrative form.
Text and opinion papers will, where possible, be pooled using the JBI-NOTARI. This will involve the aggregation or synthesis of conclusions to generate a set of statements that represent that aggregation, through assembling and categorising these conclusions on the bases of similarity in meaning. These categories are then subjected to a meta-synthesis in order to produce a single comprehensive set of synthesised findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible the conclusions will be presented in narrative format.
Support for this project has been provided by the Australian Learning and Teaching Council (ALTC) Ltd, an initiative of the Australian Government Department of Education, Employment and Workplace Relations. The views expressed in this paper do not necessarily reflect the views of the ALTC.
The reviewers also wish to acknowledge the other members of the Australian Learning and Teaching Council project team: Dr Kerry Hoffman, Dr Sharon Bourgeois, Dr Sharyn Hunter, Dr Jennifer Dempsey, Dr Sarah Jeong, Noelene Hickey, Carol Norton, Raelene Kenny, and Karen Jeffrey.
Conflicts of interest
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Appendix I: JBI critical appraisal tools
Appendix II: JBI Data extraction tools