Secondary Logo

Journal Logo

Department: Education Extra

Simulation + student response systems = success

Zaloom, Joan M. MSN, RN, CNE; Shannon, Mary RN, ACRN

Author Information
doi: 10.1097/01.NME.0000668364.62993.4b
  • Free

Integrating technology into nursing education and actively engaging students in their own education enhances student success. By recognizing that the current student population is comprised of the “tech-driven” generations, it would be advantageous to use simulation and student response system (SRS) activities as educational modalities. Innovation in the classroom increases student motivation and enables educators to evaluate high standards for patient care. This article discusses the use of simulation technologies and the SRS in nursing education.

New ways to learn

Nurse educators have the challenging goals of preparing students to graduate, pass a licensure exam, and transition into a complex, fast-paced, technologic healthcare environment. To achieve our educational goals, we must adapt and integrate the current evidence-based teaching methods into our routines. Student-centered education, or active learning, improves student success on exams and in practice, allowing educators to teach a variety of learners. Examples of active learning methods include unfolding case scenarios, role playing, the flipped classroom, and the SRS. The American Association of Colleges of Nursing and the National League for Nursing (NLN) support active learning strategies. And many active teaching methods that shift the focus from teacher to student are supported by recent research.

According to the NLN, more than 50% of the current nursing student population across ADN, LPN, and BSN programs are between ages 24 and 40. These students possess characteristics native to living in the digital age. They were raised with cellphones, computers, and video games. They use internet search engines to provide immediate information and instant messaging and texting to communicate. These students want to be able to complete tasks quickly and multitask. Their preference is teamwork and immediate feedback; to “do” instead of “just know.” They develop critical thinking through experimentation and active participation.

According to an extensive research study aimed at corporate marketers done by Microsoft Corporation in 2015, the average attention span of humans has decreased from 12 seconds in 2000 to 8 seconds in 2013. The study linked this decline to the increased use of digital devices that deliver information rapidly and enable the user to complete multiple tasks quickly. Another finding from the same study revealed that digital lifestyles are increasingly making people more efficient at processing information and recording it to their memories in a short amount of time. The study recommends that to engage people, information must be delivered quickly in short bursts. Although this research was aimed at corporate marketers, we can apply the same principles to our advantage in the classroom by using teaching methods that include giving students information quickly, actively engaging them, allowing them to work in teams, and providing them with immediate feedback, much like during an unfolding simulation scenario or in an SRS presentation.


Simulation is defined as a technique to replace or amplify experiences found in real life. It can be used to improve patient safety and enhance care. This type of learning and teaching strategy enables students to explore simple and complex nursing skills in a safe, comfortable environment before the actual patient experience. Simulation accomplishes the goal of relating clinical knowledge to practical knowledge, ensuring that the student is well prepared. It also fosters student confidence because mistakes are corrected and skills mastered in a lower-pressure environment. Feedback is provided from instructors, as well as from peers during and after the simulation.

Simulation fidelity is measured by how closely the experience reflects or mimics reality. Due to the advent of high-fidelity manikins, the use of simulation in nursing education has become common practice as a tool for nursing students to practice and review their skills and educators to evaluate student progress. The increase in the number of undergraduate nursing programs, which has led to more competition for clinical opportunities, has also contributed to the use of simulation. In addition, many acute care settings are limiting how many nursing students are allowed on the unit at one time and restricting what activities nursing students can perform to ensure patient safety. Simulation offers the experience necessary to safely transition into practice.

Simulation begins with providing a trustworthy and supportive environment to ensure engagement. Learning goals and how to meet them must be established before starting the simulation. The simulation requires students to take on various roles to accomplish the goals of the scenario. The roles can be RN, family member, physician, and so on. The high-fidelity manikin can have signs and symptoms associated with a disease process, and vital signs and symptoms can be adjusted according to measures being implemented by the students.

Debriefing after the scenario is one of the most important aspects of the simulation experience. Debriefing encompasses detailed discussions between the students and the instructor about what worked and what didn't work during the simulation. Questions get discussed and evaluated, such as: What could've been done differently? How can that skill be improved? How can the patient experience be improved?

Student response systems

Known by various names, including audience response system, personal response system, or clicker system, the SRS is the convergence of mobile technology and education in today's classroom environment. Basically, the SRS allows instructors to pose questions and gather students' responses during an interactive presentation. Students respond to the questions using a clicker or mobile device. A receiver is used to bridge communication between the student's device and a software program on the instructor's computer. In addition, the receiver gathers the data and can display a summary of the students' responses on the instructor's computer or a classroom smartboard.

The SRS isn't a new invention—the US Air Force developed the first clicker system in the 1950s. Electronic devices were employed in the course of training personnel by incorporating multiple-choice questions into films. Following this technology's implementation in military educational settings, Stanford University and Cornell University adopted clicker systems in the late 1960s. In general, the application of clickers within these and other universities yielded largely unsatisfactory results. Through trial and error at many educational institutions over the next 40 years, the SRS has evolved and won favor with both educators and students.

Web-enabled SRS technology is now widely used because of its ease of use with mobile devices, the ability to collect and store student data over the internet, and the appeal of using a mobile device for students who are from the digital age. A 2019 study done by the Pew Research Center on Information and Technology revealed that 98% of adults ages 18 to 29 own a smartphone. This statistic reveals how important it is for digital-age students to be engaged with their world.

In adult learning theory, the teacher is a facilitator and learning is a collaborative experience. This involves a shift from the instructor-centered responsibility to teach content toward a student-centered approach to learning and the development of critical-thinking skills. The SRS offers advantages for both the teacher and student in this area. SRS technology promotes active learning, increases participation, and provides students and faculty with immediate feedback that reflects comprehension of content and increases faculty-student interaction. In addition, the level of expertise needed to use an SRS system is minimal and the amount of time the instructor uses to incorporate SRS into a course is fairly consistent with other changes made to classroom presentations to incorporate active learning methods.

Better patient outcomes

Our students compel us to change the delivery of information so it's appealing and engages them for meaningful, long-term learning to occur. As educators, we've chosen to use two evidence-based teaching methods in our medical-surgical nursing course—computer-assisted simulation and the SRS—and we've seen an increase in student engagement and enthusiasm for learning. These improved and ever-evolving educational tools will contribute to producing more confident, well-prepared nurses, which will result in better patient outcomes.

consider this


A group of medical-surgical nursing students were participating in a class to learn about septic shock. A combination of simulation and SRS was used to both engage the students and assess knowledge. Before the simulation experience, students were presented with a review of septic shock, the purpose of the scenario, learning objectives, and expectations for the simulation. In this scenario, the patient was an 87-year-old woman brought to the ED from a long-term-care facility with new-onset confusion, a BP of 100/60 mm Hg, a heart rate of 110 beats/minute, a respiratory rate of 30 breaths/minute, a temperature of 101°F (38.3°C), and decreased urine output. The patient had an indwelling urinary catheter in place from the long-term-care facility.

In the simulation lab, the students worked in groups of six on an interprofessional team consisting of two RNs, one certified nursing assistant, one family member, one observer, and one physician. Throughout the simulation, feedback was given to the students related to their actions and tasks completed. After the students completed the septic shock simulation, a debriefing was conducted to discuss outcomes of the scenario. To further assess the student's knowledge of septic shock, an SRS presentation was done during which the students interacted with the unfolding septic shock patient scenario by answering multiple choice questions.

The students verbally rated the simulation and SRS presentation. Their reviews were very favorable regarding class participation, engagement, enthusiasm for learning, and the speed of feedback received. Many requested more classes using both these teaching methods.


Abrahamson L. A brief history of networked classrooms: effects, cases, pedagogy, and implications. In: Banks DA, ed. Audience Response Systems in Higher Education: Applications and Cases. Hershey, PA: IGI Global; 2006:1–25.
    American Association of Colleges of Nursing. 2019 annual report.
      Billings DM. ‘Flipping’ the classroom. Am J Nurs. 2016;116(9):52–56.
      Caputi L. Certified Nurse Educator Review Book: The Official NLN Guide to the CNE Exam. 2nd ed. Philadelphia, PA: Wolters Kluwer Health; 2019.
        Judson E, Sawada D. Learning from past and present: electronic response systems in college lecture halls. J Comput Math Sci Teach. 2002;21(2):167–181.
          Klien K, Kientz M. A model for successful use of student response systems. Nurs Educ Perspect. 2013;34(5):334–338.
            Lavoie P, Clarke SP. Simulation in nursing education. Nursing. 2017;47(7):18–20.
            Lippincott Nursing Education. 11 Active learning strategies to engage active learning. 2018.
              National League for Nursing. A vision for the changing faculty role: preparing students for the technological world of health care. 2015.
                National League for Nursing. Biennial survey of schools of nursing, 2016.
                  Pew Research Center. Mobile fact sheet. 2019.
                    Scribd, Inc. Microsoft attention spans research report. 2015.
                      Sofer D. The value of simulation in nursing education. Am J Nurs. 2018;118(4):17–18.
                      Walters B, Potetz J, Fedesco HN. Simulations in the classroom: an innovative active learning experience. Clin Simul Nurs. 2017;13(12):609–615.
                        Wolters Kluwer Health, Inc. All rights reserved.