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The Effects of Human Patient Simulators on Basic Knowledge in Critical Care Nursing with Undergraduate Senior Baccalaureate Nursing Students

Hoffmann, Rosemary L. RN, PhD; O'Donnell, John M. CRNA, MSN; Kim, Yookyung PhD

Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare: July 2007 - Volume 2 - Issue 2 - p 110-114
doi: 10.1097/SIH.0b013e318033abb5
Empirical Investigations

Background: The nursing literature to date has offered many descriptive accounts utilizing human simulation in undergraduate and graduate nursing curricula. However, the nursing literature remains sparse in the area of studies that evaluate the effectiveness of simulation on knowledge attainment in critical care using standardized assessment tools. The primary aim of this paper is to report on a study that investigates whether participation in instruction involving human patient simulators, in conjunction with a traditional clinical experience, improves professional competence in senior-level undergraduate nursing students related to basic knowledge of critical care nursing.

Methods: This study (n=29) used a pre- and posttest repeated-measure design. Senior baccalaureate nursing students enrolled in an advanced medical-surgical nursing course participated. Students were assigned to groups and completed 7 weeks of traditional clinical experience (45 hours total) and 7 weeks of high-fidelity human simulation (45 hours total). Students completed the Basic Knowledge Assessment Tool-6 (BKAT-6) prior to traditional clinical and on the last day of human simulation experience.

Results: Results showed a significant improvement on the BKAT-6 overall and a significant improvement in 6 subscales of the BKAT-6.

Conclusion: Instruction involving high-fidelity human simulation is a viable teaching strategy to improve basic knowledge acquisition as one essential attribute needed for professional competence.

From the Departments of Acute and Tertiary Care (R.L.H., J.M.O.) and Health and Community Systems (Y.K.), University of Pittsburgh School of Nursing, Pittsburgh, PA.

Reprints: Rosemary L. Hoffmann, Department of Acute and Tertiary Care, University of Pittsburgh School of Nursing, 3500 Victoria Boulevard, 336 Victoria Building, Pittsburgh PA 15261 (e-mail:

The authors have indicated they have no conflict of interest to disclose.

Knowledge, as one attribute related to competency, is essential for the professional nurse. Some additional attributes identified include communication, technical skills, clinical reasoning, values, and reflection in daily practice that benefit the individual and community being served.1 According to The Essentials of Baccalaureate Education for Professional Nursing Practice, professional nurses must possess distinct core competences, core knowledge, and traits that promote role development.2 Examples of identified core competencies include knowledge related to pharmacology, pathophysiology of disease, assessment, and management of symptoms.2 In addition, the professional nurse's core knowledge base must encompass information related to health promotion, illness management, and health care technology.2 Knowledge is an essential component in the American Nurses' Association Code of Ethics as well as the National League of Nursing Hallmarks of Excellence in Nursing Education.3,4 Likewise, there are various criteria used to measure nursing knowledge related to competency. Examples of objective measures include standardized tests, performance evaluations for technical skills, or successful completion of a health care facility's orientation program. Competence for entry into practice is commonly determined in the United States as passing a licensure examination. To assure that graduates possess basic knowledge competency essential for practice, it is the responsibility of nurse educators to design and evaluate curricula that develop these necessary attributes prior to graduation.

Recent advances in technology offer an opportunity to teach and evaluate these attributes. These advances include the availability of life-sized, computer-controlled human simulators (HS) that are programmed to mimic events encountered in clinical practice. HS as a part of a teaching-learning system have the potential to objectively measure mastery of many psychomotor skills as well as subjectively measure competency of professional traits such as communication, delegation, and interdisciplinary teamwork. HS provides a mechanism to simulate real-world events and provide feedback to actions, questions, and decisions in a controlled environment. With HS, students can be taught in a setting that does not compromise patient safety.5–9 HS guarantees standardized student exposure to benchmark or required clinical experiences. It facilitates learning how to manage emergent events such as cardiac arrest, acute respiratory distress, or unstable dysrhythmias. In the simulation laboratory (SL), students develop interventions based upon their knowledge base, and observe consequences of their actions that are effective (or ineffective). This teaching strategy empowers the learner to solve difficult issues and develop competencies by creatively employing multiple systems and tools.10 Finally, using video camera capability, faculty can review the scenario with the student during a “debriefing” session. Faculty and students can collaboratively analyze the decisions and suggest or model actions that are more appropriate. The opportunity to learn from one's mistakes is a powerful teaching tool.

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The purpose of the study was to investigate whether participation in instruction involving high-fidelity human-simulated technology in conjunction with a traditional clinical experience improves basic knowledge of critical care nursing with senior baccalaureate nursing students.

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Study Method

This study used a pre- and posttest repeated measured design. Data were collected from September to December 2002. All students enrolled in a senior-level medical surgical nursing course, Advanced Clinical Problem Solving (ACPS), were asked to participate. Following institutional review board approval, informed consent was obtained from 29 senior-level baccalaureate nursing students. ACPS is a required 15-week course that includes 45 hours of classroom lecture and 90 hours of clinical experience. Students completed the first 45 hours of clinical experience on a general medical surgical or stepdown unit and the remaining 45 hours, during the second half of the term, in the SL. The traditional clinical experiences were one day a week (6.5 hours) for 7 weeks on the same hospital unit. Traditional clinical experiences resembled similar experiences in other baccalaureate nursing programs and included hospital units with patient diseases of the cardiac, neurology, respiratory, renal, and musculoskeletal systems. Hospital regulations required a maximum of eight students per clinical group under the direct supervision of a university faculty member. Therefore, based on enrollment in the course, seven to eight students were randomly assigned to groups. All students enrolled in ACPS were first-semester senior baccalaureate nursing students. As a result of the homogeneity of the students in relation to successful completion of prior required clinical nursing courses, group assignments were made that exposed the student to a different patient population from prior required courses. Consequently, if a student had the majority of clinical experiences on a surgical unit, he or she was assigned to a medical unit. Students remained in their respective groups for both their traditional clinical and HS experience.

At midpoint, students completed the remaining clinical experience in the SL. One day per week (6.5 hours) in the SL was the allotted time for the participants. Students role played various scenarios of typical patient situations they may encounter postgraduation. In the scenarios, each student was assigned a different health team member role, thus fostering independent and interdependent decision making. The following roles were consistent for every scenario: primary registered nurse (RN), first responder, unlicensed assistant personnel, charge nurse, recorder nurse, and medical doctor. Depending on the scenario, additional roles were included such as a laboratory technician or respiratory therapist. The assigned health team member roles rotated for each scenario. This allowed the students to experience different health team member responsibilities, especially the role of the professional nurse.

During the 7 weeks in the SL, each group of students participated in at least four scenarios. The scenarios included acute myocardial infarction progressing to ventricular tachycardia, pulmonary edema from heart failure, drug overdose, and decreased level of consciousness and elevated intracranial pressure from a motor vehicle collision. The scenarios reflected either the most common admitting diagnoses witnessed in the metropolitan area or those commonly tested on the state licensure examination. A core set of principles, outlined on a debriefing form, was stressed in every scenario that included knowledge (medication and nursing), communication, judgment, planning, and resource management. These core principles guided discussion in the debriefing sessions. While seven or eight students engaged in the scenario, the remaining students enrolled in the course viewed and critiqued their actions in a distant classroom. Usually 15 minutes were allotted to a scenario and 10 minutes for structured debriefing. The debriefing sessions were lead by two faculty members responsible for the course. One faculty member conducted the debriefing session with the group of students who participated in the scenario. The other faculty member led the debriefing session with the remaining students in the course who observed in the distance education classroom. To facilitate consistency of both faculty members in the debriefing sessions, instructor guidelines were developed that emphasized major concepts in each of the core principles on the debriefing form. For example, in the scenario acute pulmonary edema from heart failure, some appropriate concepts discussed for the nurse listed under the core principle judgment included assessing the breath sounds, oxygen saturation, and blood pressure, in addition to elevating the head of the bed. The concepts included on the instructor debriefing guidelines were not all-inclusive. The concepts in each core principle that guided debriefing sessions were developed based on evidence based practice.

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Human Simulator

Resources available in the School of Nursing include a simulation laboratory equipped to replicate a clinical unit or operating room, state-of-the-art mannequin (SimMan, Laerdal Corp), video equipment, and onsite (one-way mirror) and distance (classroom) viewing capabilities. SimMan is a high-fidelity reproduction of an average-sized adult equipped with an interactive software package that allows the operator to simulate normal and abnormal physiologic conditions encountered in clinical practice.

The SL in the School of Nursing includes equipment (operating room table and light, anesthesia machine, bedside monitor, mechanical ventilator, intravenous supplies) that allow faculty to simulate an operating room, critical care, or acute care room. The adjacent control room contains the simulation control computer and audiovisual components. A one-way mirror enables unobtrusive observation of the simulated care area with real-time response. SL activities are transmitted via digital feed to a distant classroom. For the purpose of this study, the SL resembled either an emergency or acute care room.

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Basic Knowledge Assessment Tool-6

Knowledge attainment was measured using the Basic Knowledge Assessment Tool-6 (BKAT-6). The BKAT-6 was administered on the first day of class (baseline) and 3-months after baseline (post-HS). The BKAT-6 is a 100-item paper-and-pencil test that measures both the recall of basic information and the application of basic knowledge in practice situations.11 This tool is often used to measure basic knowledge in critical care for new graduates or registered nurses entering a critical care area. The items measure content related to critical care nursing practice in the following subscales: cardiovascular, monitoring lines, pulmonary, neurology, endocrine, renal, gastrointestinal/parenteral, and other.11 The total number of questions pertaining to each subscale are as follows: 31 cardiovascular, 11 monitoring lines, 10 pulmonary, 11 neurology, 9 endocrine, 8 renal, 8 gastrointestinal/parenteral, and 12 other.11 Validity was established through a panel of experts.11 Cronbach's coefficient alpha (α) was used as the measure of internal consistency reliability. The reliability of the BKAT-6 was α = 0.80, measured on 101 critical care nurses from seven states in the United States.9 Sample questions from the BKAT-6 that relate to each of the eight subscales are found in Table 1.

Table 1

Table 1

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Study Results

A repeated measures design using paired sample t-tests was used to analyze the data. Significance was determined by P values <0.05. The analysis showed a significant improvement at 3 months post-HS on the BKAT-6 overall and the following six subscales on the BKAT-6: cardiology, monitoring lines, pulmonary, neurology, renal, and other (Table 2). Two subscales on the BKAT-6 that did not show significant findings were endocrine and gastrointestinal. Importantly, these two areas were not addressed in the simulation scenarios.

Table 2

Table 2

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We have demonstrated that following a combined intervention consisting of equivalent times in a simulation and traditional clinical experience, one aspect of professional competence, basic knowledge, showed a significant improvement compared with baseline as measured by BKAT-6. Although there is little published translational simulation data within the nursing profession, these results are similar to other studies with anesthesia and medical students. Ali et al.5 found that simulation improved the performance of senior medical students with advanced trauma life support training. In another study, anesthesia residents showed that retention of advanced cardiac life support guidelines using a simulation program were better than simple textbook review 10 to 11 months after course training.9 Flanagan et al.12 reported that participating in evolving situations and debriefing with HS were powerful mechanisms helping nursing students identify learning needs to manage crisis management situations. These results substantiate the importance of simulation education to retain knowledge through a variety of senses including visual, hearing, and active participation.

The scenarios that incorporated cardiopulmonary concepts showed significant differences on four subscales of the BKAT-6 (cardiac, monitoring lines, pulmonary, and other). In the study, students incorporated aspects of the nursing process as they role played scenarios related to dysrhythmias, cardiac arrest, respiratory difficulty, and chest pain. Students had frequent opportunities to assess, prioritize, plan, and implement nursing care to patients with a cardiac abnormality. Furthermore, in each scenario, students incorporated technical skills that included the use of various monitoring lines, such as a blood pressure cuff, pulse oximetry, and electrocardiogram. The incorporation of monitoring devices was included in all scenarios, not only those specific to cardiac issues. According to Toth and Richie,11 the scale “other” includes areas of infection control, hypothermia, burns, and spiritual care. Students were expected to include aseptic techniques and universal precautions in the various role play scenarios.

The targeted exposure to the above situations may have produced the positive results in the study. HS can be available at any time to fit curriculum needs, are programmed to simulate selected conditions, are reproducible, and provide standardized experiences for all students.7,13 Knight14 states that a skill is best learned systematically in a safe environment. HS offers nursing faculty and students repeated exposure to various patient situations. Furthermore, one key advantage of HS is the ability to make mistakes without jeopardizing patient safety. Eliminating this fear may have created a positive learning environment for the students.

Thoughtfully planned group work has the capability to produce positive effects in student behavior. Although students are assigned to a specific group for clinical experiences, they seldom work together outside of the simulation experience. In the SL, students work together to problem solve various patient situations. This experience may have contributed to the positive results shown on the BKAT-6 following HS. According to Bruffee,15 group work fosters the development of professional behaviors through collaboration, goal setting, decision making, critical and creative thinking. Faculty and students observed evidence of these behaviors during each scenario performance in the SL. The debriefing sessions allowed the group members to critique their behaviors and apply theory to actual patient situations. This aspect of group work strengthens critical thinking skills through inference, inductive and deductive reasoning.16–18

The curriculum structure created limitations to the study. Sample size was limited by the number of students registered for the course. All students were required to complete the first half of the course on a general medical-surgical unit. Therefore, results obtained may not be solely the result of HS. To justify the impact of simulation experiences on basic knowledge, additional studies should test two groups of students. Teaching experiences for one group of students should include simulation and clinical opportunities while a control group would only be exposed to a traditional clinical experience. Hopefully, this or a similar design would substantiate the importance of simulation as a teaching strategy for undergraduate students. HS was a new teaching strategy in the undergraduate program. Even though faculty explained the concept and its lack of impact on the final grade for the course, many students expressed additional anxiety throughout the experience. This may have affected some final results in the study. With additional exposure in subsequent classes, some anxiety may be alleviated.

Future research involving the transfer of knowledge as a result of HS postgraduation is needed. The BKAT-6 has reported validity and reliability in the area of basic critical care knowledge. It does not measure other attributes of professional competency such as interdisciplinary communication, clinical reasoning and values. To substantiate the importance of HS as a teaching strategy with all aspects of professional competence, standardize formats for evaluation of psychomotor skills, professional attitudes, and benchmarks as standards of care need to be developed and tested. These additional formats will validate the essential improvement associated with HS.

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HS as a teaching strategy in conjunction with a traditional clinical experience showed significant results overall on the BKAT-6 and several subscales. The future of HS in curriculum development is in its infancy and will not replace the traditional clinical environment. University faculty must stress to administration the importance of HS to seek funding sources for its incorporation into the curriculum. Once available, it is the responsibility of creative faculty members to incorporate simulation experiences throughout the curriculum. The nursing profession and health care community will reap the benefits of increased competence and improved patient safety.

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The authors would like to thank Kelly Meno and Kelly Mowry, two CRNA students at the University of Pittsburgh School of Nursing, for their help with data collection and scenario development during the study.

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Human simulation; Teaching strategy; Undergraduate education; Knowledge

© 2007 Society for Simulation in Healthcare