Graded simulation for nursing students : Nursing made Incredibly Easy

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Department: Education Extra

Graded simulation for nursing students

Murphy, Kathryn DNSc, NP

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Nursing Made Incredibly Easy! 15(6):p 6-9, November/December 2017. | DOI: 10.1097/01.NME.0000525558.82774.11
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High-fidelity simulation can assist nursing students with exercising the critical-thinking skills necessary for today's healthcare environment. Clinical simulation immerses students in a realistic scenario in a safe environment. It's during this experience that students are required to integrate key concepts and apply appropriate skills. However, simulation evaluation has been met with some controversy in the nursing literature. There are varying opinions on whether simulation should be graded, as well as multiple measurement tools to grade the experience.

Some educators adhere to a nonthreatening use of simulation in their program, feeling that increasing student anxiety by grading the experience can negatively affect the learning process. Faculty members who may favor evaluating students on handling emergent situations often don't want to add the role of evaluator to the multiple instructor roles inherent in simulation, such as role playing and managing the computer software and other technologic aspects of the simulation. Most instructors are assigned according to interest and availability, which can lead to inconsistent evaluation.

To address these problems, Chemeketa Community College utilizes simulation throughout the 2-year associate degree program. In the first quarters of the program, students are given information about the cases in each scenario before the day of simulation. The students can then review any skills or concepts likely to occur in the simulation. Progressively, more is expected from the students as they advance in the program, with each course focusing on key concepts and skills. These courses use a rubric to give feedback on simulation performance to each student, but not as part of the course grade. It isn't until the final quarter of the program that the simulation is graded. Let's take a closer look at the process.


The graded simulation is part of the “Preparation for Entry into Practice” course in which the grade is an accumulation of points rather than traditional testing. The students are in a clinical preceptorship with an RN for 160 hours over a 4-week period. The graded part of the course consists of a variety of group activities, each constituting a certain percentage of the grade. The simulation accounts for 10% of the total grade.

In an orientation to the graded simulation course, objectives are shared with the students, but no actual information about the simulation scenarios is provided. The rubric is given out ahead of time so that students can be aware of the expectations. Students are encouraged to use open lab time to practice skills, such as tracheostomy care or complex dressing changes, before the scheduled simulation because any skills or concepts taught in the program are fair game to use in the scenarios.


On the day of the simulation, a schedule of what will occur and a blank evaluation rubric are given to the students. For the faculty members performing the simulation, there's a summary of key points to discuss during the debriefing and key concepts and skills in each part of the scenarios. An explanation of the rubric for grading is also given to the faculty members.

The actual situations involved in the simulation are two unfolding patient cases, each with three different admissions about 6 months apart. Students, in groups of two or three, are randomly selected to be assigned as the nurse to care for both patients either during the first, second, or last admission. Concepts across the three admissions include cultural sensitivity, death and dying, language barriers, family care, effective communication with healthcare providers, and organization of care.

After a brief orientation to equipment and the patient charts, a faculty member in the RN role gives report to the first two students up for the scenario. The students are encouraged to ask question of the RN at the time of the report. Patient charts are then available for review, but students are encouraged to operate as if on the clinical floor where there's limited time to review patient records.

The use of the nursing process and critical thinking is crucial to passing the simulation. There are times when the selected intervention can negatively affect the patient or where key errors in care can occur, such as noticing a chest tube isn't connected, contributing to a decline in patient progress, or catching a medication error verbally prescribed by a provider that could harm the patient if executed. Midway through each admission, a buzzer rings and the next student takes over caring for the patient, emphasizing the 24/7 aspect of nursing care.

When students aren't involved in the simulation, they sit at a table in full view. Each student is given the patient's chart for that particular scenario so that they can follow along with what's happening and have information to assess what they would do differently if in the scenario. Also, these students can take notes on specific feedback they can offer during the debriefing.

Debriefing is a faculty-guided review of the simulation utilizing critical reflection that can assist with each student's learning needs. As a student progresses in the nursing program, the type of debriefing must also progress. What the novice needs from a debriefing naturally differs from what the student who's about to graduate needs. In this graded simulation, the debriefing is still guided by a faculty member, but often peers may direct or change the focus. In addition, more global topics, such as the operational problems of the healthcare arena and ways that the new nurse can impact these systems, may be discussed. Students may be more comfortable giving sensitive feedback to other students, just as their nursing role will require in the work environment. During the debriefing, faculty members need to allow the flow to be dictated by the students rather than a preordained script.

Evaluation rubric


The faculty members involved in the simulation fill out a rubric for each student's performance while watching the scenario unravel. They then meet as a group to discuss student performance and share thoughts on the point value to be given for each area. Students also fill out a rubric on their own performance, which is included in the discussion.

Our rubric incorporates concepts from the Lasater Clinical Judgment Rubric, Clark Simulation Evaluation Rubric, Seattle University Creighton Competency Evaluation Instrument, Sweeney-Clark Simulation Performance Rubric (based on Patricia Benner's classic Novice to Expert Theory), and QSEN Based Simulation Evaluation Rubric. The themes used in these simulation evaluation tools include patient-centered care and assessment, evidence-based nursing interventions and clinical judgment, communication and teamwork, and safety. However, including so many areas to assess can make the rubric lengthy and burdensome to complete.

We assess four key areas: communication, organization/prioritization, critical thinking/nursing process, and debriefing (see Evaluation rubric). There's a possible 2.5 points for each area, for a total of 10 points as a perfect score. The student can score 2.5, 1.25, or 0 points for each section, with no variation on these points, and each category outlines what constitutes a 2.5, 1.25, or 0 score.

To receive the top score in communication, the student needs to communicate effectively using therapeutic principles, give a complete Situation-Background-Assessment-Recommendation (SBAR) report, and respond effectively during care and emergent situations.

To meet the top score in organization/prioritization, the student needs to demonstrate efficiency and organization in all actions, show evidence of preplanning, prioritize quickly and appropriate in all situations, and perform skills confidently and competently.

For a top score in critical thinking/nursing process, the student needs to show consistent evidence of the use of critical thinking in execution of the nursing process.

Lastly, to receive the top score in debriefing, the student needs to contribute significant information to the debriefing outside of his or her own performance that assists peers' learning. In other words “she did a good job” isn't acceptable for a top score.

The other possible scores of 1.25 or 0 have similar standards, but allow for the student who only meets the standards part of the time or doesn't address one of the standards. If a critical error has occurred, a 0 may be given in a category.

The graded results are given to the students, with specific written feedback reflecting the score. Overall, feedback from students in an end-of-course survey is positive for both the simulation experience and the grading rubric.

Real world reward

Nursing educators have been sensitive to the increased stress that students experience and how it can affect learning. In particular, the design of simulation includes ways to decrease the stress factor during the process. However, by grading the final simulation in a nursing program and offering realistic feedback, we can launch students into the real world of nursing in which resiliency and the ability to give and accept feedback from both peers and other healthcare team members aren't only necessary, but vital to clinical practice.

did you know?


The first use of simulation in nursing started with the Chase Hospital Doll commissioned by Hartford Hospital in 1911 to assist students with learning. Although use of the Chase Hospital Doll faded, the use of simulation in nursing continued to grow. In 1960, the Laerdal Company created Resusci Anne, a more sophisticated manikin, to teach CPR to healthcare providers. Soon, nursing schools were using the manikin not only to teach CPR, but also as part of low-fidelity simulation.


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