12/7/15

Simulation
Learning for
Student Nurses

WHAT IS SIMULATION?
A safe means of teaching psychomotor skills and physical
assessment (Beauchesne & Douglas, 2011)
...a technique, not a technology, to replace or amplify real experiences with
guided experiences, that evoke or replicate substantial aspects of the real
world in a fully interactive fashion (Aebersold & Tschannen, 2013)

Jaclyn Spinelli, Emily Heiland, Carly Bove,

Camille Firestone, Tonya King, Megan Deschenes,
Ashley Bresnahan, Corey Suzukawa, Amy Aragon Pollock

HISTORY
1969- introduced to healthcare education to teach anesthesia
residents how to insert ET tubes
1988- more developed version to teach medical and anesthesia
practitioners crisis management and technical skills
Utilized in nursing schools for fewer than 10 years
(Beauchesne & Douglas, 2011)

LEVELS OF SIMULATION
Low-Fidelity role play, noncomputerized mannequins,
task- trainers
Mid-Fidelity standardized
patients, computer programs
or video games
High-Fidelity computerized
mannequins
In-situ in the site where the
learner is practicing (i.e. ER
trauma bay, surgical suite)
(Abersold & Tschannen, 2013)

PICOT QUESTION
"Does the use of simulation exercises
(I) included in student nurses (P)
undergraduate education (T) compared
to education without simulation
exercises (C) improve the student's
critical thinking and self-confidence in
clinical skills (O)?

HYPOTHESIS
Simulation learning will be effective in:
- improving student nurses critical thinking
- improving self-confidence in performing
clinical skills
Simulation should be implemented in
undergraduate nursing education curriculum.

12/7/15

CURRENT PRACTICES IN SIMULATION

Clinical experience
Case studies
Recruitment of patients

THE NEED FOR SIMULATION

Increased number of undergraduate programs
Reduction in number of nursing students allowed to
care for one patient at a time (Hayden et al., 2014)
Restrictions on skills students can perform in
clinical facilities (Hayden et al., 2014)
Challenges of clinical education: (Hayden et al., 2014)
Decreased length of patient stay
Varying patient acuity

(Hayden et al., 2014)

CURRENT PRACTICE: NATIONAL

2002: Nehring and Lashley found 66 nursing
programs using patient simulators (Nehring & Lashley, 2004)
2010: NCSBN found 917 nursing programs using
medium or high-fidelity patient mannequins in their
curriculum (Hayden et al., 2014)
National survey found 87% of respondents were
using simulation in their programs: (Hayden et al., 2014)
medical-surgical, obstetric, pediatric,
foundations

CURRENT PRACTICE: LOCAL

UA
SILC lab with 3 computerized simulation manikins, IV lab
(Steele Innovative Learning Center, 2015)

ASU
Over 15 simulated patients (LRC educational simulation program, 2015)
NAU (Flagstaff & Tucson) (Learning real-life health care in a simulated environment, 2015)
High-fidelity manikins and men, women and infant simulators

Banner Simulation Medical Center Mesa

2015)

ICU, ED, OR, NICU, 8 bed recovery wing

(Simulation at Banner Health,

CURRENT PRACTICE: STATE

Limited availability of clinical experiences and reduced
student-faculty ratios led to greater use of simulation
Arizona State Board of Nursing found nursing programs in
AZ to require an average of 599 clinical hours (McGinty, 2014)
37 BSN programs reported an
average of:
68 hours of simulation learning
40 hours of virtual clinical
experiences (McGinty, 2014)

CURRENT LITERATURE
Findings show that students using simulation believed that they were better able to transfer
their knowledge to the clinical setting, decrease their anxiety, improve learning and
communication skills, and developed leadership and stress management skills.
Students reported that the HPS assisted them in understanding concepts, provided a valuable
learning experience, helped to stimulate critical thinking abilities and decrease anxiety, and should
be included in undergraduate education. The findings of this study regarding students positive
perceptions of HPS as a teaching strategy are consistent with data reported throughout the health
education literature (Howard, Ross, Mitchell, & Nelson, 2010).
The study provided evidences on the effectiveness of the SIMPLE program in enhancing the
students' preparedness for their transition to graduate nurse practice (Dawood et al., 2013).
It also improved their learning and communication skills with other healthcare professionals.
Moreover, they reported that simulation enabled the development of their leadership and stress
management skills in a nonthreatening environment (Kaddoura, 2010).

12/7/15

CURRENT LITERATURE
Findings show that simulation increases critical thinking.

Participants who used EIS over a 2-week period increased their scores for critical thinking disposition
overall and on three subscales (Weatherspoon, Phillips, & Wyatt, 2015).
In seven subcategories of critical thinking, three exposures to the simulation courseware produced CT
gains in the prudence and intellectual eagerness subcategories, and the overall simulation experience
produced CT gains in the prudence, systematicity, healthy skepticism, and intellectual eagerness
subcategories (Shin, Ma, Park, Ji, & Kim, 2014).
There was a statistically significant relationship between overall high-fidelity human simulation
performance and overall critical thinking disposition scores (Cramers V = 0413, P = 0047) (Fero et al.,
2010).
Results suggest that high- and low-fidelity simulations are both associated with increases in critical
thinking scores (Goodstone et al., 2013).

Findings show that simulation increase self confidence.

The results indicated an overall improvement in self-confidence and competence across the
semester (Blum, Borglund, & Parcells, 2010).
The participants reported that simulation contributed significantly to building their confidence in their
critical thinking skills (Kaddoura, 2010).

LIMITATIONS OF RESEARCH
Bias
Evaluation of students from their own instructors

Setting
Limited space and simulation capabilities
Outside of the US

Samples
Small size
Convenient populations
Not diverse students
Unrealistic
Will simulation performance reflect in real practice?

STRENGTHS OF RESEARCH
Samples
Large size
Randomized population
Diverse levels of education
Low drop out rates
Strict study protocols
Simulations improved critical thinking
Instructors attended learning sessions
Extended time periods of studies
Ideal Simulation Settings
(Blum, Borglund, & Parcells, 2010), (Dawood et al., 2013), (Fero et al., 2010), (Goodstone et al. , 2013), (Howard, Ross, Mitchell, & Nelson,
2010), (Kaddoura, 2010), (Shin, Ma, Park, Ji, & Kim, 2014), (Smith & Hamilton, 2015), (Weatherspoon, Phillips, & Wyatt, 2015)

EVIDENCE BASED NURSING RECOMMENDATIONS

THAT SUPPORT BEST PRACTICE
We recommend:
The utilization of human simulation training as opposed to
interactive or paper case studies (Howard, Mitchell, & Nelson, 2010;
Weatherspoon, Phillips, & Wyatt, 2015).
Virtual reality preparations for at least a week prior to start of
simulation with unlimited access to this information (Smith &
Hamilton, 2015; Weatherspoon, Phillips, & Wyatt, 2015).
Repeated exposure to a range of scenarios in several different
nursing settings (Shin, Ma, Park, Ji, & Kim, 2014; Kaddoura, 2010).

(Blum, Borglund, & Parcells, 2010), (Dawood et al., 2013), (Fero et al., 2010), (Goodstone et al. , 2013), (Howard, Ross, Mitchell, & Nelson,
2010), (Kaddoura, 2010), (Shin, Ma, Park, Ji, & Kim, 2014), (Smith & Hamilton, 2015), (Weatherspoon, Phillips, & Wyatt, 2015)

EVIDENCE BASED NURSING RECOMMENDATIONS

THAT SUPPORT BEST PRACTICE
Encouraging groups or pairs to perform simulation together
(Dawood et. al, 2013).
Initiating pre-conference going over objectives of simulation
(Goodstone et. al, 2013).
Changing the individual roles and utilizing interprofessional
teamwork during simulations (Dawood et. al, 2013; Blum, Borgland,
& Parcells, 2010).
Use of video recording of simulation for debriefing purposes
(Kaddoura, 2010).

IMPLEMENTATION
An outline plan to implement a simulation lab and integrate simulation learning into the
courses in a BSN program in Arizona at a public university that does not yet have
simulation learning.
Step One (3 months)
Create a vision
Demonstrate what will be achieved, who is involved, how the lab works, and how it
improves outcomes based on EB research of simulation learning in nursing schools

Develop a cost-effective business plan

Outline initial and continued fiscal obligations

Present these to the nursing school board of directors

Gain approval for implementing simulation learning/lab

Once approved, help board find funds within and outside of their budget
Raise the needed amount of additional funds through donations, tuition increase,
shareholders, fundraiser, etc.
(Rothgeb, 2008)

12/7/15

IMPLEMENTATION
Step Two (6 to 8 months)
Acquire the space needed for the lab: ~1,000 - 1,200 square
For 2 simulation rooms, lab managers office, equipment storage space, 2
observation/conference rooms, and a control room

Purchase equipment
3 mannequins, maintenance and warranties for mannequins, scenarios/
access to simulation software, computer equipment, sound and video
equipment, hospital room furniture, wall suction and oxygen, various
medical supplies, etc.

Hiring
Construction company, IT company to set up technology, university IT
employee for on-call maintenance, and lab manager

Construct the lab as defined in the vision plan & set up all tech equipment

IMPLEMENTATION
Step Three (1 to 2 months)
Provide simulation training for all faculty
Define simulation learning objectives and institute simulation
learning into the curriculum
Develop plans and procedures for scenarios
Teach students and instructors how to use pre-simulation and
post-simulation resources
Begin using simulation learning in the BSN program starting
with the next incoming cohort of ~40 students
(New White Paper, 2012) (Rothgeb, 2008)

(New White Paper, 2012) (Rothgeb, 2008)

COST ANALYSIS
Facility: 1,000-1,200 sq ft.
New building/construction company = $145,000 (Building-Cost.net, 2013)
To rent space = $18,000/year (Building-Cost.net, 2013)
Equipment: Human Patient Simulators (HPS) cost between $30,000-$150,000
(Howard et al., 2010)

3 mannequins = $90,000 - $450,000

Simulation Software: No cost to the college due to the students buying access
1-year access card = $100-$150 (Elsevier.evolve.com, 2015)
40 student class = $4,000 - 6,000 per year for college if included in
class fees
Computer Equipment (sound/video):
2 simulations rooms = $5,000 for purchase/installation (Rothgeb, 2008)

OVERALL COST
Start-up cost ~ $1 million dollars (on high end)
Includes cost of building a lab, equipment (mannequin, sound,
computers), room furniture/medical supplies, faculty costs/training,
purchase and set-up of software and simulation technology
Cost would decrease with use of already standing building,
donations of equipment/supplies, and having the students
purchase their own software simulation access ~500,000 (on lower
end)
Cost Upkeep per year ~ $10,000
Includes maintenance cost of building and supplies that need to be
purchased for the lab when used

COST ANALYSIS
Simulation room furniture and equipment:
Donations from local hospitals and healthcare facilities (stretchers, oxygen
equipment, suction set-up/equipment)
Medical supplies and equipment = $1,000 - 8,000 a year depending on what
is donated (Hicks et al., 2009)

Staff training:
Each faculty will have an orientation day to the simulation center that involves
learning how to work the simulation mannequins and run necessary
equipment
Lab manager will train the staff = cost associated with training of lab
manager and standard instructors salaries
Lab Manager annual salary ~$40,000 (Glassdoor.com, 2015)

University IT support specialist on staff

Average annual salary ~$60,000 (Glassdoor.com, 2015)

COMPARISON OF COST
University of Arizona SILC
$1.3 million to expand an already established simulation center (Humphrey,
2007)

Northern Arizona University

$85,000 to add sim-mans to already established simulation center (Flagstaff
Medical Center Foundation, 2015)

University of California, San Francisco

$1.3 million to build a facility to accommodate skills learning with healthcare
professionals. First year cost (UCSF Library, Teaching and Learning Center Business
Plan, 2010).
Implementation despite cost: Despite the costs associated with implementing human
patient simulation (HPS) as a teaching strategy in nursing curricula, the authors conclude that
such an expense is warranted in view of the greater learning outcomes that were achieved by
students from all types of programs who participated in the HPS group (Howard et al., 2010).

12/7/15

RISK

BENEFIT
Institution

Institution

Standardized curriculum

High cost

The same scenarios can be used for all the students

There is a high financial start up and yearly cost to maintain simulation programs

Physical space needed

Employers benefit from more clinically prepared nurses

Higher quality nursing education

Future Nurses

Future Nurses

Team work

Fidelity

Students learn the use and importance of collaborative teamwork

Equipment - how much the mannequins replicate real patients

Communication

Psychological - students may not take the simulation as seriously as if it was a real
patient

Skills

Environment - how realistic the surrounding environment is

Extra tuition cost to the nursing students

Patient

(Hicks,Coke & Li, 2009) (Rothgeb, 2008)

Students are able to practice interprofessional communication

Skills are improved in a controlled environment without risking harm to patients
Students are learning both by participating and observing

Improvements in critical thinking and self confidence

(Dawood et al., 2013)

(Rothgeb, 2008)

Less competent nursing care without simulation

BENEFIT

EVALUATION

Patient
No direct risk from simulation learning in nursing schools
Reduced number of errors committed with nurses who used simulated
learning
More competent nursing care from simulation-trained nurses

Outcomes based on PICOT hypothesis:

Nursing students will use simulation exercises in their
undergraduate education to improve critical thinking skills,
evidenced by a 10% improvement in Critical Thinking Deposit
Inventory (CTDI) score.
(Weatherspoon, Phillips, & Wyatt, 2015)
Nursing students that utilize simulation learning in their
undergraduate education will self-report improved self
confidence in their nursing skills using a pre- and postsimulation survey.

(Rothgeb, 2008)

EVALUATION
Outcome of implementation plan:
Ninety percent of the forty nursing students that
utilize the proposed implementation plan will
pass the NCLEX exam within six months of
graduation.

SUMMARY
INTRO: Simulation is fairly new to nursing; research for best practices still in progress.
DESCRIPTION OF ISSUE: Simulation learning has been implemented in the majority (87%) of
nursing programs in the US (Hayden et al., 2014).
SUPPORTIVE STUDIES: Nine separate studies were reviewed. Wide variation in sample sizes,
facilities and evaluation methods provided diversity yet still had similar conclusions.
DISCUSSION OF BEST PRACTICE: Using human simulation (no paper case studies), presimulation preparation and conference, wide range of scenarios, one or more week for preparation,
open access to simulation facility, group or pair performance, interprofessional teamwork, and role
changing are all best practices for optimal simulation learning experiences (Dawood, et. al, 2013).
APPLICATION TO FACILITY: Implementation into facility is involved process that would take
around a year to develop, construct, and initiate a simulation lab (Rothgeb, 2008).
COST ANALYSIS: Very costly endeavor. Can be up to a $1 million investment (Hicks et al., 2009).
RISK VS. BENEFIT: Major risk is the cost to the facility. Major benefit is the health of future
patients (Rothgeb, 2008).

12/7/15

REFERENCES

REFERENCES

Aebersold, M. & Tschannen, D. (2013). Simulation in nursing practice: The impact on patient care. The Online Journal of Issues in Nursing, 18(2).
doi:

10.3912/OJIN.Vol1No02Man06

Glassdoor. (2015). Retrieved from http://www.glassdoor.com/Salaries/index.htm

Goodstone, L., Goodstone, M., Cino, K., Glaser, C. A., Kupferman, K. & Dember-Neal, T. (2013). Effect of simulation on the development

Beauchesne, M. A., Douglas, B. (2011). Simulation: Enhancing pediatric, advanced, practice nursing education. Newborn & Infant Nursing

of

critical thinking in associate degree nursing students. Nursing Education Perspectives. 34(3), 159-162. doi:

Reviews, 11(1), 28-34. Retrieved from http://www.medscape.com/viewarticle/743501_1

Blum, C., Borglund, S., & Parcells, D. (2010). High-fidelity nursing simulation: impact on student self-confidence and clinical competence
.

International Journal Of Nursing Education Scholarship, 7(1). doi: 10.2202/1548-923X.2035

Building-Cost.net. (2013). Retrieved from http://www.building-cost.net/CompMatrix.asp

study:

A longitudinal, randomized, controlled study replacing clinical hours with simulation in prelicensure nursing

education. Journal of

Dawood, R., Koh, Y., Kowitlawakul, Y., Lau, S., Liaw, S., and Zhou, W. (2013). Easing student transition to graduate nurse: A SIMulated
professional

http://dx.doi.org/10.5480/1536-5026-34.3.159
Hayden, J. K., Smiley, R. A., Alexander, M., Kardong-Edgren, S., & Jeffries, P. R. (2014). Supplement: The NCSBN national simulation

learning environment (SIMPLE) for final year student nurses. Nurse Education Today, 34, 349-355. doi:

Hicks, F.D., Coke, L., & Li, S. (2009). The effects of high-fidelity simulation on nursing students knowledge and performance: A pilot study.

http://dx.doi.org/10.1016/j.nedt.2013.04.026
Elsevier-Evolve. (2015). Retreived from https://evolve.elsevier.com/cs/products

National Council of State Boards of Nursing, (40), I-27. doi: 978-0-9822456-5-1

Howard, V. M., Ross, C., Mitchell, A. N., & Nelson, G. M. (2010). Human patient simulators and interactive case studies: A comparative

Fero, L. J., ODonnell, J. M., Zullo, T. G., Dabbs, A. D., Kitutu, J., Samosky, J. T., & Hoffman, L. A. (2010). Critical thinking skills in nursing
students:

Nursing Regulation, 5(2), C1-S64. Retrieved from http://atireallife.com/wp-content/

uploads/2014/08/JNR_Simulation_Supplement.pdf

analysis of learning outcomes and student perceptions. Computers, Informatics, Nursing, 28(1), 42-48. doi:

Comparison of simulation-based performance with metrics. Journal of Advanced Nursing, 66(10), 21822193. doi:
10.1111/j.1365-2648.2010.05385.x

10.1097/NCN.0b013e3181c04939.
Humphrey, G. (2007, August 15). College of nursing kicks off 50th anniversary. UA News. Retrieved from

Flagstaff Medical Center Foundation. (2015). Retrieved from http://nau.edu/Giving/Donor-Recognition/Directory/FMCF/

http://uanews.org/story/college-nursing-kicks-50th-anniversary
Kaddoura, M. A. (2010). New graduate nurses' perceptions of the effects of clinical simulation on their critical thinking, learning, and
confidence.The Journal of Continuing Education in Nursing, (41), 506-16. doi:
10.3928/00220124-20100701-02

REFERENCES

REFERENCES

LRC Educational Simulation Program. (2015). Retreived from https://nursingandhealth.asu.edu/lrc/lrc-educational-simulation-program

McGinty, D. (2014). Clinical facility utilization by arizona nursing programs. Retreived from
https://www.azbn.gov/Documents/education/Nursing Programs/
FINAL REPORT MCGINTY CLINICAL 2012--corrected.pdf
Learning Real-Life Health Care in a Simulated Environment. (2015). Retrieved from http://www4.nau.edu/insidenau/bumps/2006/12_6_06/
sim.htm
Nehring, W. M., & Lashley, F. R. (2004). Current use and opinions regarding human patient simulators in nursing education: An international
survey. Nursing Education Perspectives, 25(5), 244-248. doi:

Smith, P. C., & Hamilton, B. K. (2015). The effects of virtual reality simulation as a teaching strategy for skills preparation in nursing students.
Clinical Simulation in Nursing, 11(1), 52-58. doi: http://dx.doi.org/10.1016/j.ecns.2014.10.001
Steele Innovative Learning Center. (2015). Retrieved from https://www.nursing.arizona.edu/about-us/simulation-lab
UCSF Library, Teaching, and Learning Center Business Plan (2010).
http://saa.ucsf.edu/sites/saa.ucsf.edu/files/PDF/WASC/Appendix%204.%20Business%20Plan%20for%20Teaching%20and%20Learning
%20Center.pdf
Weatherspoon, D., Phillips, K., & Wyatt, T. (2015). Effect of electronic interactive simulation on senior bachelor of science in nursing students'
critical thinking and clinical judgment skills. Clinical Simulation in Nursing, 11(2), 126-133. doi:

http://dx.doi.org/10.1043/1094-2831(2004)025<0244:CUAORH>2.0.CO;2
New White Paper: Designing a Simulation Lab Thats Right for You. (2012, January 24). Retrieved from

http://dx.doi.org/10.1016/j.ecns.2014.11.006

http://www.kahlerslater.com/thought-leadership/white-paperdesigning-a-sim-lab-thats-right-for-you
Rothgeb, M. K. (2008). Creating a nursing simulation laboratory: A literature review. The Journal of nursing education, 47(11), 489-494.
Retrieved

from http://cupublic.chw.org/media/BestPractices/BPClinicalEducation/Documents/Rothgeb.pdf

Shin, H., Ma, H., Park, J., Ji, E. S., & Kim, D. H. (2014). The effect of simulation courseware on critical thinking in undergraduate nursing
students:

Multi-site pre-post study. Nurse education today. doi: 10.1016/j.nedt.2014.12.004

Simulation Education at Banner Health. (2015). Retreived from

http://www.bannerhealth.com/About+Us/
Innovations/Simulation+Education/_Simulation+Education.htm