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Comparison of Clinical Options

High-Fidelity Manikin-Based and Virtual Simulation

Díaz, Desiree A. PhD, RN-BC, CNE, CHSE-A, ANEF; Anderson, Mindi PhD, APRN, CPNP-PC, CNE, CHSE-A, ANEF, FAAN; Hill, Peggy P. MSN, RN, CHSE; Quelly, Susan B. PhD, RN, CNE; Clark, Kristen MSN, RN; Lynn, Melissa MSN, RN, CMSRN, CHSE

Author Information
doi: 10.1097/NNE.0000000000000906


Undergraduate nursing students are expected to perform and understand the implementation of patient-centered care across the life span in various health care settings.1 Obtaining clinical placements for nursing students in pediatrics2,3 and obstetrics3,4 is an issue. The use of simulation drills has been added to some programs,3 whereas others have ultimately decreased clinical hours in specialty nursing areas, such as pediatrics.5

Simulation as a methodology has been deemed one solution to mitigate clinical placement issues.2,3 Results from the study by the National Council of State Boards of Nursing showed simulation can also be used to replace portions of clinical hours, up to half, with parallel student outcomes.6 The International Nursing Association for Clinical Simulation in Nursing (INACSL) Standards of Best Practice: Simulation(SM) should be employed in all simulation-based education (SBE) to ensure adequate quality and consistency.7,8 Consistency can be obtained through various types of simulation modalities, such as a manikin-based high-fidelity simulator9 or virtual simulation.10 Manikin-based high-fidelity patient simulation (HFPS) is the use of a life-like computerized manikin that resembles human functionality and realism. A virtual simulation creates a digital clinical patient experience within an online platform.12 However, some states do not regulate or guide the administration or type of simulation.13

Virtual Simulation and Comparison of Methodologies

Advantages of virtual simulation are that it may be engaging to learners,14,15 requires less resources than some other methods,12 is easily accessible,4,15,16 allows for repeated practice,4,12,15,17 and may help learners prepare for clinical or the workforce.15,16 Specifically, with the virtual simulation product vSim® for Nursing,18 several studies have been conducted using this modality. Different content areas have been the focus including fundamentals,19 maternity,4 medical-surgical,12,15,20 and surgical21 nursing. A different number of virtual cases have been assigned to learners such as 1,4,21 2,15,20 4 with 2 repeated,12 and 10.19 Compared to a control group (HFPS), a study has found no significant difference in outcomes compared to virtual simulation.15

Research has been done to compare participant outcomes from manikin-based simulation (different fidelity) versus virtual or computer-based in varying levels of nursing students, including graduate. While one study showed no differences between groups on knowledge,4 some differences in groups were found between modalities in knowledge or clinical performance.22,23 Student outcomes from the different modalities used for clinical replacement were not evaluated.

Gaps and Aims

Use of virtual simulation as a clinical replacement has been discussed as a needed study.20 The authors aimed to compare the effects of 25% clinical replacement with manikin-based HFPS or virtual simulation (intervention groups) for specific pediatric-obstetric content outcomes. The outcomes measured for both intervention groups included (1) knowledge (immediate/delayed 1-week post-simulation), (2) simulation design/fidelity, and (3) time-on-task. To ensure that substituting clinical hours with simulation did not have negative student outcomes, pass/fail grades for the course were also compared to a control group (previous semester) who did not receive clinical substitution with simulation, that is, had face-to-face pediatric/obstetric clinical practice. The National League for Nursing Jeffries Simulation Theory24 was the underpinning.

Simulation Platform

vSim® for Nursing Maternity and Pediatric provides virtual simulations on a web-based platform.25 Optimal learning was assumed by completing the entire program from suggested reading (module 1) to guided reflection questions (module 6). Six different clinical scenarios were used in both intervention groups: 3 were pediatric, and 3 were obstetric. Pediatrics patient content included dehydration, sickle cell, and respiratory distress. Obstetrics content included preeclampsia, postpartum hemorrhage, and prolapsed cord. Because the same companies produced both products (virtual and manikin-based), the scenarios were consistent among both modalities.


Design and Sample

This study used a quasi-experimental design. Institutional review board approval was obtained. Participants included BSN students at a large university in the southeastern United States. A convenience sample of approximately 400 BSN students was eligible to participate and included student cohorts from 2 consecutive years. The control group used for clinical practice pass/fail was the graduates from the prior year, where students had no SBE for the pediatric/obstetric content. The intervention groups were actively enrolled in the associated pediatric/obstetrics course.

Pre-simulation, Prebriefs, and Simulations

Pre-simulation activities were provided with didactic and reading content to prepare the students for the upcoming SBE.26 A prebrief27 was delivered to the students via online web module or in person and was consistent between groups. For the HFPS groups, an orientation was given face-to-face during the simulation day by each specific facilitator. A script was used for consistency among groups. All students received the virtual product at no cost because of grant funding. Virtual groups were given an orientation to the product at the beginning of the day. Patient information was provided via the product and was the same as the HFPS groups.


The intervention groups were randomly assigned to manikin-based (HFPS) or virtual simulation by the roll of a die upon entering the prebrief. All students were instructed to bring their computers in case they were assigned to the virtual simulations.

Students participating in HFPS were divided into groups of 4, with 2 students serving as participants and 2 playing the role of participant-observers.28 A participant-observer is one who has a vicarious and active role, which could include actively watching.28,29 Debriefing for all students participating in HFPS was conducted using Debriefing for Meaningful Learning©.30 This was standardized across groups. All facilitators were also given guided reflections to maintain consistency across the groups. All participants of the HFPS simulations were kept at a constant 45-minute time investment, which comprised 15 minutes per scenario and 30 minutes for debrief. A total of 6 trained facilitators were used for the HFPS. One facilitator monitored the virtual group.

Those participating in the virtual simulation group were put in a room all together with their individual computers. Students were instructed to repeat each simulation until a set competency score (set at 90%) was reached. When this score was reached, they could then move to the next simulation. No specific order of simulations was required. Debriefing was done with the feedback provided in the program.12,19,20,25 At the end of each 7-hour day, a whole group debriefing on all scenarios was led by the facilitator.

Regardless of the group, all simulations took place on the same day. Both HFPS and virtual were led by either the principal investigator or the coinvestigator to maintain consistency. Participation in the study portion was voluntary and confidential, and study forms were collected from all whether completed or not to increase anonymity. Both simulation intervention groups took 6 vendor-written posttests25 based on essential criteria determined in the simulations immediately following the SBE and 1 week following the intervention. All students completed demographics and the validated Simulation Design Scale (Student Version).31 The control group had 2 SBE activities in their entire program, with all pediatric/obstetric clinical experiences being face-to-face. Only demographics and aggregate pass/fail grades for clinical practice were collected from this group.


Demographics included gender, ethnicity, program, and reported simulation experience. Knowledge acquisition was evaluated for the intervention groups (HFPS and virtual) with 6 vendor-created, content-specific posttests provided within the virtual product.15,25 The post-tests were originally created for the virtual product25; however, permission to use and give to all participants identical posttests via paper/pencil was obtained from the vendor to maintain consistency among groups. Six posttests, each with 10 items, were scored individually (0–10) and added together as a composite (0–60). Posttests were given immediately following the simulation and at the 1-week follow-up. The time span between the first and second posttests was limited to only 1 week because of firm prearranged dates for course simulation experiences and semester schedules.

Time-on-task was aimed at determining the amount of time it took a student to complete the simulated virtual experiences. Students were asked to self-report on a time log.

For all groups (control, HFPS, and virtual) clinical success was measured by earning a passing grade. Clinical pass/fail grades were obtained from University reports (aggregate).

Data Analysis

Data analyses were conducted using the Statistical Package for the Social Sciences (SPSS) version 25.0 (IBM, Chicago, Illinois). An a priori level of statistical significance was set at P < .05. Descriptive statistics were summarized. Nonparametric, rank-base testing was conducted. A Kruskal-Wallis test was conducted to determine if there were differences between groups for composite knowledge scores. Assumptions of analysis of variance were not met.


Participants’ Demographics

Study participants (n = 361) ages ranged from 18 to 58 years, with 60% between the ages of 18 and 22 years. Most participants (81%–93%) identified as female (Supplemental Content, Table 1,

Intervention groups were HFPS (n = 119) or virtual simulation (n = 134). The control group that completed the demographic survey items was n = 108 out of a total sample of N = 120 (12 students did not complete demographics). The total final sample was 361 BSN students.

Knowledge Acquisition (Immediate/Delayed)

Knowledge differences were noted for preeclampsia content in both the initial posttest and posttest 2 (Table). The delayed 1-week posttest resulted with significant differences between groups for the postpartum hemorrhage and pediatric dehydration content. Sickle cell anemia content on delayed posttest 2 was not significant; however, the initial posttest demonstrated a significant difference.

Table - Difference in Knowledge Between Groups
Content Area Immediate Posttest 1-wk Posttest
h P h P
Composite score 3.725 .054 .992 .319
Postpartum hemorrhage 1.741 .190 5.82 .020
Preeclampsia 12.002 <.001 11.772 <.001
Prolapsed cord 1.91 .170 .008 .930
Pediatric respiratory 3.08 .08 .042 .837
Pediatric dehydration .030 .862 4.43 .040
Pediatric sickle cell 12.68 <.001 .382 .537
h statistic is the Kruskal-Wallis H test (a nonparameteric version of the one-way ANOVA). It is used to compare value distribution between 2 or more groups (Laerd, 2018).32

Time-on-Task (Virtual)

The amount of time spent in each scenario varied from a little over 30 minutes to slightly over an hour. The scenarios that took the most time (mean) were both on obstetric content (Supplemental Content, Table 2, The entire day lasted 7 hours.

Clinical Practice Pass/Fail

There were no pediatric/obstetrics clinical failures noted among any group.


As nursing programs increasingly incorporate simulation into the prelicensure clinical curriculum, it is essential to determine the efficacy of replacing face-to-face clinical hours with HFPS, as well as with more cost-effective, efficient, convenient, and accessible virtual experiences.4,12,15,16,19,23


Our study found no significant difference between HFPS and virtual intervention groups on knowledge acquisition, which supports the use of virtual simulation to augment or replace potentially more costly and/or resource-intensive HFPS.16,19,23 Equally effective virtual simulation technology may be particularly beneficial for use in online nursing courses.10,16

Time Investment

The time invested in a HFPS experience is constant, and facilitators can help control the direction of the debrief. However, the virtual experience allows participants to attempt individual scenarios until learning or a set competency score has been achieved. Time investment for the student may vary. Interestingly, in another study, students spent on average slightly over 28 (SD, 9.61) minutes on each virtual case for fundamentals, which was shorter than the mean time of any of virtual cases.19 Gu et al19 reported that virtual simulations took less time than manikin-based simulations; however, in this study, this was not always the case.

Overall and Limitations

The authors learned many lessons about incorporating and substituting both manikin-based and virtual simulation for clinical practice hours. Some of those related to virtual, including faculty development, are outlined in a separate article.10 Limitations were noted. Numerous nursing staff facilitators were used in the HFPS groups. Although multiple facilitators were required for the total day, there was consistency within each simulation as a standardized template and format were used. Students in the virtual simulation group were required to complete the simulation together within a classroom at the college. The benefit of virtual simulations is the ability to complete them in a home environment. Yet, to keep the environment consistent and to ensure the simulations were completed, students were not afforded this opportunity. However, having students come to campus, for study purposes, strengthened the study results.

Another limitation was the posttests. One week between the first and second posttests was not ideal and may not have captured knowledge retention.33 However, a 1-week period between knowledge tests has been used previously but was noted as a limitation.33 Because of a planned course examination, several participants dropped out of the study and did not complete the delayed posttest. Survey fatigue in participants could have occurred.

Implications for Nursing Education

Replacement of clinical practice with simulation may facilitate student exposure to varying patient populations and, possibly, larger numbers.23 This allows students to gain experience caring for manikin-based and/or virtual patients without a negative impact on student outcomes. Demonstrating comparable clinical placements is relevant in a time with limited sites for certain specialties, particularly pediatrics and obstetrics, as well as during public health crises such as the current COVID-19 (coronavirus disease 2019) pandemic.

Studies should investigate how best to combine different simulation modalities. Further research is needed regarding participant outcomes following clinical practice replacement with varying types of simulation and for different content areas. Simulationists may also need to lobby for appropriate application of all types of simulation with state boards of nursing.12 Regardless of strategy, it is important to follow INACSL Standards.7


The authors compared differences in nursing student outcomes between 2 intervention groups (HFPS and virtual simulation) when replacing clinical hours. There were no differences in overall outcomes between the intervention groups, and learning occurred with both modalities. Time was easier to standardize with the HFPS groups versus virtual ones, but virtual simulation allowed for repetition until a set competency was achieved.

When comparing the differences between the intervention groups and a control group, there was no change in pass/fail rate for clinical practice. In addition to the plethora of research findings on the benefits of simulation, this research demonstrates the continued benefits associated with simulation and student learning outcomes. Further research is needed to examine student outcomes of different types of simulation modalities when used for clinical practice replacement.


The authors acknowledge the University of Texas Arlington College of Nursing and Health Innovation and Texas Higher Education Coordinating Board for assisting with study design and integration. The authors also thank the Laerdal Foundation for Acute Medicine for funding this study.


1. American Association of Colleges of Nursing (AACN). The Essentials of Baccalaureate Education for Professional Nursing Practice. Available at Published 2008. Accessed January 10, 2020.
2. Bowling AM, Cooper R, Kellish A, Kubin L, Smith T. No evidence to support number of clinical hours necessary for nursing competency. J Pediatr Nurs. 2018;39:27–36.
3. Moxley E, Waller M. Alternative strategies for providing clinical experiences in a family nursing course. Teach Learn Nurs. 2019;14(3):173–178.
4. Cobbett S, Snelgrove-Clarke E. Virtual versus face-to-face clinical simulation in relation to student knowledge, anxiety, and self-confidence in maternal-newborn nursing: a randomized controlled trial. Nurs Educ Today. 2016;45:179–184.
5. Society of Pediatric Nurses (SPN). Child Health Content in the Undergraduate Curriculum. Society for Pediatric Nurses. Available at Published 2017. Accessed January 20, 2020.
6. Hayden JK, Smiley RA, Alexander M, Kardong-Edgren S, Jeffries PR. The NCSBN National Simulation Study: a longitudinal, randomized, controlled study replacing clinical hours with simulation in prelicensure nursing education. J Nurs Regul. 2014;5(2):suppl. Available at
7. INACSL Standards Committee. Standards of best practice: SimulationSM. Clin Simul Nurs. 2016;12:S48-S50. doi:10.1016/j.ecns.2016.10.001
8. Lioce L, Meakim CH, Fey MK, Chmil JV, Mariani B, Alinier G. Standards of best practice: simulation standard IX: simulation design. Clin Simul Nurs. 2015;11(6):309–315.
9. Fowler L. High-Fidelity manikin-based simulation: A study of implications for interprofessional healthcare practitioner education at the Associate Degree Level of study [dissertation]. Terre Haute, IN: Indiana State University; 2013:
10. Roye J, Anderson M, Díaz DA, Rogers M. Virtual simulation incorporation into an undergraduate nursing curriculum. Nurs Educ Perspect. In press.
11. Lioce L (Ed.), Lopreiato J (Founding Ed.), Downing D, Chang T, Robertson JM, Anderson M, Diaz DA, Spain AE (Assoc Eds.); and the Terminology and Concepts Working Group. Healthcare Simulation Dictionary. 2nd ed. Rockville, MD: Agency for Healthcare Research and Quality; 2020. AHRQ Publication No. 20-0019.
    12. Foronda CL, Swoboda SM, Henry MN, Kamau E, Sullivan N, Hudson KW. Student preferences and perceptions of learning from vSim for Nursing™. Nurse Educ Pract. 2018;33:27–32.
    13. The Florida Legislature. (2019). The 2019 Florida Statutes. The Florida Legislature web site. Available at Published 2019. Accessed January 20, 2020.
    14. Shin H, Rim D, Kim H, Park S, Shon S. Educational characteristics of virtual simulation in nursing: an integrative review. Clin Simul Nurs. 2019;37(C):18–28.
    15. Wright RR, Tinnon EA, Newton RH. Evaluation of vSim for Nursing in an adult health nursing course: a multisite pilot study. Clin Simul Nurs. 2018;36(2):84–89. doi:10.1097/CIN.0000000000000388
    16. Bryant R, Miller CL, Henderson D. Virtual clinical simulations in an online advanced health appraisal course. Clin Simul Nurs. 2015;11(10):437–444.
    17. Bayram SB, Caliskan N. Effect of a game-based virtual reality phone application on tracheostomy care education for nursing students: a randomized controlled trial. Nurs Educ Today. 2019;79:25–31.
    18. Wolters Kluwer. vSim® for Nursing. Wolters Kluwer website. Available at Accessed May 8, 2020.
    19. Gu Y, Zou Z, Chen X. The effects of vSim for Nursing™ as a teaching strategy on fundamentals of nursing education in undergraduates. Clin Simul Nurs. 2017;13(4):194–197.
    20. Foronda CL, Swoboda SM, Hudson KW, et al. Evaluation of vSim for Nursing™: a trial of innovation. Clin Simul Nurs. 2016;12(4):128–131.
    21. Tjoflåt I, Brandeggen TK, Strandberg ES, Dyrstad DN, Husebø SE. Norwegian nursing students’ evaluation of vSim® for Nursing. Adv Simul. 2018;3:10. doi:10.1186/s41077-018-0070-9
    22. Erlinger LR, Bartlett A, Perez A. High-fidelity mannequin simulation versus virtual simulation for recognition of critical events by student registered nurse anesthetists. AANA J. 2019;87(2):105–109.
    23. Padilha JM, Machado PP, Ribeiro A, Ramos J, Costa P. Clinical virtual simulation in nursing education: randomized controlled trial. JMIR. 2019;21(3):e11529. doi:10.2196/11529
    24. Jeffries PR. The NLN Jeffries Simulation Theory. Washington, DC: National League for Nursing; 2016.
    25. Laerdal Medical and Wolters Kluwer Health. vSim for Nursing | Maternity and Pediatric. Wolters Kluwer web site. Available at Accessed January 12, 2020.
    26. Tyerman J, Luctkar-Flude M, Graham L, Coffey S, Olsen-Lynch E. A systematic review of health care presimulation preparation and briefing effectiveness. Clin Simul in Nurs. 2019;27(C):12–25.
    27. Page-Cutrara K. Use of prebriefing in nursing simulation: a literature review. J Nurs Educ. 2014;53(3):136–141. doi:10.3928/01484834-20140211-07
    28. Johnson BK. Simulation observers learn the same as participants: the evidence. Clin Simul Nurs. 2019;33:26–34.
    29. Levine HG, Gallimore R, Weisner TS, Turner JL. Teaching participant-observation research methods: a skills-building approach. AAEQ. 1980;11(1):38–54.
    30. Dreifuerst KT. Using debriefing for meaningful learning to foster development of clinical reasoning in simulation. J Nurs Educ. 2012;51(6):326–333. doi:10.3928/01484834-20120409-02
    31. National League for Nursing (NLN). Simulation Design Scale (Student Version). Available at Published 2005. Accessed January 12, 2020.
    32. Laerd. (2018). Kruskal-Wallis H test, SPSS statistics. Available at–wallis–test–in–spss.php.
      33. Kim JH, Kim WO, Min KT, Yang JY, Nam YT. Learning by computer simulation does not lead to better test performance on advanced cardiac life support than textbook study. J Educ Perioper Med. 2002;4(1):E019.

      clinical hours; nursing students; replacing clinical practice with simulation; simulation; virtual simulation

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