Increasing patient acuity and the complexity in today's healthcare environments contributes to the developing expectation that newly graduated nurses will possess strong patient care skills and use well-developed clinical judgments when providing nursing care. Nurse educators are continually faced with rapid systemic and technical changes, thus presenting challenges for both the instructors and students in preparing nurses for employment. Nurses are expected to analyze a patient's situation and be able to process the information quickly and to make appropriate and safe clinical decisions.1 Employers are expecting that nurse educators will produce nurse graduates who are ready and prepared to make a rapid transition into the role of a nurse and provide safe and effective nursing care.2 There are an increasing number of nursing schools that are integrating the use of patient simulation (PS) in the educational experience of their students. This study examines the prevalence of schools using PS technology in baccalaureate nursing (BSN) programs in the United States.
Nursing education is based on didactic and interactive learning.3–6 Nursing school faculty provide guided experiences to support students learning during the short period of time they spend in class and clinical situations. When students finish their degree requirements, they take national and state licensing boards to test their knowledge. However, the examination does not test critical thinking and judgment that is needed when they are employed as registered nurses. The use of PS in nursing education standardizes essential aspects of a clinical situation in preparing students to understand and manage a similar experience when it occurs in an actual clinical environment.7–10 Mannequin-based clinical simulation education potentially offers nursing students varied clinical patient situations that are comparable with an acute setting.11–15 Simulation technology provides a risk-free, controlled learning experience that supports the learner's transfer of classroom and skills laboratory knowledge to realistic patient interactions.16–19 High-fidelity mannequins are computer-based technologically advanced simulators that are programmed to respond to the learner's action or inaction.4,14,16,20–23
Conventional nursing education emphasizes teaching facts and the memorization of content knowledge. Nurse educators apply that knowledge to case studies or clinical problems.24 Technology-based care environments are not static in PS or in real clinical settings. In many localities, nursing educators have experienced shrinking availability of clinical sites and fewer clinical experiences for nursing students. Nurse educators are seeking alternate strategies for clinical preparation for nursing students.
The purpose of this exploratory descriptive study was to assess current use or nonuse of PS models in undergraduate nursing schools in the United States. This study selected potential respondents through the National League for Nursing (NLN) that accredits baccalaureate schools in the United States. The NLN as a nursing organization has supported the use of simulation in nursing education and a sponsor of a key study on PS in nursing education. However, the authors are not affiliated with either the manufacturers or the NLN.
Because there was not a valid standardized instrument available, survey questions were developed by the authors and two nurse educators who currently work with PS. An online survey was constructed to obtain data using Survey Monkey. The survey instrument consisted of 13 multiple-choice questions and one optional open-ended section for additional comments. Two questions were redrafted and amended for clarity after a short pilot study was conducted. The survey instrument was finalized and prepared for distribution in Spring 2007. Approval to conduct this study was obtained from the Colorado Multiple Institutional Review Board before distribution of the e-mail invitation for participation.
Sample Selection and Data Collection
The NLN Bachelors of Nursing Science schools list was used to identify nursing programs and the e-mail address of the dean of the school. There were a total of 241 schools of nursing with baccalaureate programs listed on the NLN website. The invitation to participate in the survey was sent to all the deans of the schools requesting that the dean or their learning laboratory managers complete the survey. A request to forward the introductory letter to the person responsible for PS was included in the text. Nineteen respondents identified their programs as not meeting the criteria of the study because they were either 2-year RN programs or RN to BS programs. The e-mail invitation was reissued to nonresponding schools 10 days after the initial online invitation. One week later, follow-up phone calls were placed to a portion of the remaining nonresponding schools resulting in no calls being returned. From the remaining 209 schools that met the criteria for the study, there were 78 responses in the final sample for a 37.3% response rate.
The survey instrument was designed to elicit information about the use of PS in the nursing schools and to assess how they were using PS in course work. All the responding schools offered BSN degrees and represented a small sample nonrepresentative of all schools in the United States. The responses to each of these questions are found in the tables.
Sixty schools that responded (78.9%) reported using PS in their schools. Of those schools who responded, 68.8% reported planning to purchase additional PS for their BSN programs. Approximately 39 (50%) of them reported using scenario-based PS situations in the educational program. The remaining 39 schools reported only using the PS mannequins for skills and task training. Eighteen schools reported replacing actual clinical hours with PS. However, the amount of hours being replaced varied significantly between schools and was reported in the open-ended comment section. Based on added comments, it was not possible to calculate a reliable mean number of hours being replaced. Twenty-one (35%) schools reported using competency or performance evaluation of students and 33 (55%) reported using PS to assess critical thinking of their students. Table 1 illustrates the responses to the stem questions posed in the survey.
Respondents who report using PS and the courses in which PS is currently being used is illustrated in Table 2. The right side of the table illustrates which courses had PS embedded within the curriculum. The left side of the table illustrates which courses used high-fidelity interactive scenarios that included the programmed mannequin to respond within the scenario. The core clinical nursing courses of health assessment, nursing fundamentals, medical/surgical nursing I and II, pediatrics, and obstetrics courses used PS with the greatest frequency in the course curriculum. These courses require nursing students to demonstrate specific clinical skills. Other more theoretical courses such as nursing leadership, cultural competence, and legal and ethical issues did not have specific PS components included and were not statistically significant. Consistently, high-fidelity scenario practice is widely used in the standard nursing clinical courses giving students realistic practice before entering the actual clinical environment. The findings for pediatrics and obstetrics are not as statistically significant as other clinical courses, possibly due to schools not having a baby simulator or a birth simulator. Whatever the case, the responses do indicate clinical significance.
The survey asked what brand of simulator they were using and whether the school was planning to purchase simulator mannequins within the next 2 years. Of the schools that did not report currently using high-fidelity PS, 68.6% did plan to purchase simulators. Sixty-six percent of responding schools that own PS products, own mannequins manufactured by Laerdal. The remaining 34% of schools own products produced by METI, Gaumguard, or other manufacturers. Table 3 represents the breakdown of brands the responding schools were intending to purchase. The majority of respondents (67%) intend to purchase Laerdal simulators for their programs and 33% plan to purchase a mix of the other manufacturer products. What was not asked were questions on the reasoning for their planned purchase? This information demonstrates the value seen by nursing schools of using PS in their curriculum.
An important educational issue assessed with the survey was the replacement of required patient clinical hours with PS. Each state licensing board determines the amount of clinical hours required per course, and it varies from state to state. There is not a national standard for required clinical hours in nursing programs. Forty percent of responding schools reported using PS to replace actual clinical hours spent previously with live patients. Of those who reported substituting PS for clinical hours, the replacement occurred primarily in the Med Surg II course. The respondents used an actual number or a percentage of hours being replaced, which made it difficult to calculate a consistent result. In addition, 55.3% of respondents reported using PS for competency testing and performance evaluation of their students as part of the course objectives. When asked whether the schools used PS experiences for testing or evaluating student critical thinking skills, 86.8% answered yes. A clear definition of this concept was not given in this survey and is the basis for future studies.
There was an option to add comments or feedback and 43 (55%) respondents offered comments. To analyze this important data, the responses were analyzed using AtlasTi, a software program that codes, indexes, and organizes responses into themes and categories. The researcher coded the responses first. A second person was asked to code the same text, and a comparison was done to ensure interrater reliability. There was a 97% match in coding and content naming conventions between the two.
Four predominant themes emerged in the analysis of the open-ended comments. The most frequent theme was related to the value of PS in the development of problem solving skills for nursing students. “Value in developing critical thinking” was described 24 times. Critical thinking and critical analysis of patient information are required of new graduates when they begin working in the dynamic and technologically complex healthcare system. The value in developing clinical synthesis skills promotes student self-confidence. During simulation, assessment of a patient situation occurs in a safe clinical environment. It was valuable to these respondent schools to use the programmed mannequins to provide students with the opportunity to care for a “patient in distress” and then participate in guided debriefing. One respondent noted that, “various situations can be created that the students might never encounter in actual clinical situations while in school.” Being able to work within the artificial environment fosters critical thinking and protects patient safety because a real patient is not involved.
A second theme was the application of PS “to prepare them for the role transition, delegation, prioritization, and critical thinking skill development.” Working in teams of nurses or working within interdisciplinary teams allows for interdisciplinary communication and role development. Students practice communication and prioritization of decisions as the programmed mannequin goes through physical changes based on the action or inaction of the student. The overall comments regarding student feedback from these experiences have “been very positive and the students love it.” Another respondent stated: “the students love the simulation and request more time with the simulators.”
A third theme that emerged was related to faculty time required to learn the technology of PS and to develop faculty competence in using PS. The faculty time required to become familiar and comfortable with the capacity, the programming, and the operation of the mannequin technology was mentioned frequently. Eleven comments addressed the need to have one faculty member designated as the lead simulation coordinator due to the time it takes to develop and prepare a simulation scenario. Faculty time constraints were cited as a deterrent to using the full capacity of PS: “I think it is going to intensify the nursing faculty shortage because the running and debriefing of scenarios is pretty faculty labor-intensive.” “There is a steep learning curve for faculty”; one Dean said that she “would like to see our faculty more engaged in learning to use simulation and incorporate PS into their courses, but that it isn't catching on.” Another participant wondered whether the lack of use of PS is due to “technology intimidation.” One respondent stated that “it is needed; however, faculty overloads prevent the time needed to develop the types of scenarios required to develop critical thinking.” These responses coincide with 50% of schools reporting using PS solely for basic assessment skills, learning laboratory tasks and procedures. The use of these relatively expensive mannequins for basic skills may correlate with the lack of faculty resources to develop high-fidelity scenarios and programming the mannequin. This is a paradox in nursing education, the desire to incorporate the latest technology but not dedicating faculty time to develop it to its greatest potential.
The fourth theme is related to the replacement of clinical time, classroom hours, and skill laboratory time with PS. Multiple respondents offered comments on the use of PS as a replacement for actual clinical hours. One respondent stated that “I hope there will be a standard recommendation from the Nursing Board for how many clinical hours can be replaced by simulation.” Another participant said: “We are building our simulation program at this time and it will replace laboratory hours and classroom hours, but not actual clinical hours at this point.” Five comments addressed using simulation to “supplement clinical experience, but not to replace those hours... clinical slots are becoming increasingly difficult to find due to increasing numbers of students and not enough clinical placement sites. The increased regulation from clinical facilities creates barriers for schools.” Two comments noted that as “technology improves, time spent with simulators can be classified as clinical hours, always with a limit, however.” One faculty member who is the course coordinator for Med Surg I and II in her school said that “I don't deny the need to work on humans, but simulated learning might relieve the crowded sites due to the burden of increasing student enrollment.” Respondents agreed that there is a place for PS in nursing education; however, simulators cannot replace human interactions between nurses and patients.
The increased use and interest in using PS in schools of nursing in the United States was being explored in this study. The results of this preliminary study describe the use of PS in the responding schools and some of the advantages and challenges faced in undergraduate nursing education. Advancing the science of nursing education through technology, informatics, and the integration of technology into teaching and learning is essential to prepare nurses for the changing healthcare environment. The goal of providing quality education that promotes critical thinking skills through active learning can be met, in part, through the use of PS in nursing education programs.
Respondents to this online survey indicate that there is growing interest of faculty to use this technology and increasing number of nursing schools have purchased or are planning to purchase PS mannequins. Faculty involvement and resources are essential to the implementation and subsequent success of using PS technology. PS provides an opportunity to integrate technology and complex situational simulation throughout BSN curricula.
Nursing schools have used low-fidelity mannequins to teach basic clinical skills to nursing students for years. Resusci-Anne and her cohort of mannequins have been used to teach what is described as the “skills and drills” where a skill is demonstrated and the student must return the demonstration without any interaction from the mannequin. The use of high-fidelity programmable mannequins and progressively complex scenarios are a relatively new phenomenon in nursing schools. PS can be a method that ensures each student has a consistent, standardized clinical experience in caring for commonly seen health disorders or critical situations that could occur in a real clinical setting. This is the advantage of using PS with students. Students faced with these situations can respond and learn from their mistakes and from each other without ever harming a real patient. The consistency of the scenarios and the ability of using this pedagogy in nursing schools offer opportunities for learning that may not always presented during their clinical placements.
The responding schools indicate that they are using PS in the usual undergraduate nursing courses that coincide with clinical experience. The replacement of actual clinical hours with PS remains controversial and unresolved. Respondents reported the problems that many schools of nursing are facing with competition for clinical sites and the reduction of sites willing to accept nursing students. This trend further complicates the growing demand for more nurses to meet the needs of the aging population and to replace nurses who are retiring from the workforce. The use of PS, although not the same as working with a real live person with the complexities that come with their experience of illness and surgery, does offer an alternative. Can it and should it replace actual clinical hours? Is a percentage of replacement hours acceptable and how do we know when it is enough? What the use of this new technology will bring in the future is yet unknown. The fact that many schools who are using PS and are planning to purchase PS mannequins within the next 2 years is an indication of this growing trend.
There are limitations related to selection of the sample population. Not all BS nursing programs are NLN accredited. Only NLN-accredited schools of nursing were sent invitations to participate in the survey. These exclusion criteria limited the number of respondents and possibly created bias in the study. The NLN alliance with Laerdal and sponsorship of the 3-year NLN/Laerdal PS study was both the reasons for choosing this site to select respondents and for the study and could also have introduced possible bias. Another limitation is the sample size and the response rate. Although the population was schools of nursing, the sample selection and those who responded do not represent all nursing schools in the United States.
Other limitations are the lack of an established and standardized survey instrument. The survey development followed established guidelines for creating a new survey, but the survey was not assessed for external validity. The lack of clarity in some of the survey's language (eg, “scenario,” “high fidelity,” and “low fidelity”) is another limitation of this study. Complexity of scenarios and the level of realism were not consistently understood among schools. Currently, there are no established standards for assessing use of PS in nursing schools.
Recommendations for Future Research
Recommendations for future research on this study are to expand the sample population to include all BS programs without limits to the accreditation granting organization. Further development of a survey instrument would provide a higher level of usable data. Clear definitions of PS terms should be included within the survey to assure consistency. Expanding the questions to clarify the precise simulation activities that replace clinical hours is needed.
There are many questions that could have been asked in this survey and were not. The use of PS in teaching patient safety in nursing practice and the use of PS in assessing student responses to critical events were not addressed. Multiple national patient safety initiatives emphasize the need to teach patient safety, especially regarding medication errors, patient falls, and prevention of nosocomial infections.25,26 Although patient safety is taught in course lectures, these nursing interventions could be taught and evaluated in a simulated situation. PS is a safe learning environment with no risk for harm to the patient and limited harm to the nursing student other than the stress of not responding to the situation in time to avert a simulated untoward patient event. PS can provide every student the opportunity to work with a patient in an emergent crisis or with serious symptom changes that rarely occur during clinical rotations. PS allows for instruction during a critical situation, so that the provision of care and teaching can occur simultaneously. Although this survey did not ask about this potential use, there is a need for this kind of information to be ascertained in a follow-up survey.
The survey did not address instructor-guided student debriefing immediately after the simulation activity. Guided reflection after the scenario invites students to reflect on their decisions and their feelings during their patient interaction. The opportunity to apply knowledge to practice with real-time feedback about their performance, their actions, interventions, and decisions are important in supporting the development of their critical thinking skills. Debriefing encourages self-reflection and provides guidance to improve the student's transference of theory to practice.27,28
There is a great need to develop valid and reliable PS scenarios and student assessment tools. Interrater reliability will strengthen tools when simulation is used for evaluating student performances. PS is the ideal place for making mistakes because corrective teaching can occur in the debriefing process. Many questions remain. Does increased complexity in high-fidelity scenarios foster clinical judgment in nursing students? Which elements of scenario design have the greatest impact on developing strong clinical judgment in nursing students? We do not have the answers for these questions.
There is little data available on developing reliable and valid scenarios and how to assess student responses to them. Similarly, there is little evidence on the efficacy of simulation in multidisciplinary team communication and fostering student problem solving ability. More research is needed to begin answering these questions. Advancing the science of nursing education through technology, informatics, and integration of technology into teaching and learning is essential to prepare nurses for the new care environments.
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