TEACHING WITH TECHNOLOGY

H I G H - F I D E L I T Y PAT I E N T S I M U L AT I O N

H i g h - F i d e l i t y Pa t i e n t S i m u l a t i o n i n N u r s i n g E d u c a t i o n :

An Integrative Review

A M Y W E AV E R
IGH-FIDELITY PATIENT SIMULATION (HFPS)

the use of realistic, simulated patients and clinical environments in the education of health care professionals is more visible
in nursing education than ever before (Jeffries, 2009; Nehring & Lashley,
2010). This presents a challenge to nursing faculty: can they justify the
investment of time and money necessary to train faculty in the use of
HFPS and incorporate the technology into their curricula? To answer
that question, it is necessary to examine the effect of HFPS on nursing
students.
HFPS provides opportunities for interactive learning that can be
used in any nursing course. It can also be used as reinforcement for traditional classroom lessons and as an adjunct to laboratory sessions.
Because competition among nursing programs for clinical sites can limit
students time in clinical rotations, HFPS has also been used as a supplement to those rotations (McCallum, 2007; Nehring, 2008). In a landmark
study, the National League for Nursing (NLN) conducted a four-phase,
national, multisite, multimethod project to design and implement models for simulation use in nursing education (Jeffries & Rizzolo, 2006).
Several tools were developed and tested in this study. Its publication
resulted in the development of a simulation model and a much-needed
upsurge of interest in the use of HFPS in nursing education.
But does the evidence support HFPS as an alternative to clinical
experience with real patients? This integrative review evaluates the findings of recently published research.

Simulation
makes for an ideal learning environment for nursing students: it mirrors
the clinical setting and mimics patients responses in a controlled setting, without the risk of students harming patients. Unpredictable
patient conditions can be included, as can the patients responses to
students interventions.The theory is that HFPS can encourage students
to push the limits of their abilities so that they can better learn what to
do in a real clinical situation. Also, HFPS allows for the repetitive teaching of skills and concepts in a variety of clinical situations (Nehring, Ellis,
& Lashley, 2001) and can be useful for students in need of remediation.
It can also provide a learning opportunity for conditions that students
may rarely encounter in a clinical setting.
HFPS can be used across the nursing curriculum. In beginning
courses, for example, it can be used to teach fundamental assessment
skills by demonstrating abnormal physical findings (Nehring et al.,
2001). In medical-surgical nursing courses, it can be used to teach students about drug and IV fluid administration. The complexity of the

Hands-On Learning, Real-Time Decision-Making

content can be altered according to the care setting, such as geriatrics,

pediatrics, obstetrics, and psychiatric nursing. HFPS can also be
employed as part of an exit exam from a nursing program to demonstrate students knowledge.
The future of educating health care professionals, including nurses,
will be challenging. The 2010 Institute of Medicine (IOM) consensus
report, The Future of Nursing: Leading Change, Advancing Health, recommends that 80 percent of all nurses have a bachelors degree by 2020, a
goal that it says will be achievable through the use of technology, including simulation, in nursing education (IOM, 2010). Further, licensing or
accrediting entities might use simulation to evaluate competency. The
IOM report To Err Is Human: Building a Safer Health System called on
health care organizations and teaching institutions to develop and use
simulation to train novice practitioners as part of an effort to reduce
medical errors (Kohn, Corrigan, & Donaldson, 2000). If public pressure
to reduce errors becomes strong enough, the federal government could
set forth regulations requiring the use of simulation in the education of
health care professionals (Gaba, 2004).
Method A systematic literature search was conducted using the fol-

lowing databases: Cumulative Index of Nursing and Allied Health

Literature (CINAHL), Educational Resources Information Center
(ERIC), Dissertation Abstracts, PubMed, and Google Scholar. A search
with the phrase patient simulation produced results that were too broad,
and so Boolean searching with the term AND was performed for the
remaining searches. A search using high-fidelity patient simulation AND
nursing education produced results that were too narrow; the most pertinent results came from a search using patient simulation AND nursing
education. The search was done until an overlap in the articles was
observed.
All of the articles found through the patient simulation AND nursing
education search and the high-fidelity patient simulation AND nursing education search were hand reviewed. Also conducted was an ancestry search
reading article titles in the reference lists of articles obtained in the
database searches to determine whether other articles might be relevant. Careful attention was paid to terminology because authors use
various terms when referring to HFPS.
Hand searches explored all literature from 1998 to April 2008. The
year 1998 was chosen because Nehring et al. (2001) reported that, at
the time, only one article had been published (in 1998) about the use of
HFPS in undergraduate nursing education. Information found before
that date focused on low- and medium-fidelity simulation.

RESEARCH

A B S T R AC T

An integrative review was undertaken to analyze studies published since 1998 on the use of high-fidelity patient simulation (HFPS)

in undergraduate nursing education. This review found that HFPS benefits nursing students in terms of knowledge, value, realism, and learner satisfaction; findings were mixed in the areas of student confidence, knowledge transfer, and stress. Further research in these and other areas will determine
whether its increased use is warranted.

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INCLUSION AND EXCLUS ION CRITERIA A priori inclusion criteria for the search included HFPS in nursing education and quantitative
studies. Initially, only articles involving baccalaureate nursing programs
were included in the search, but later articles on associate degree and
diploma programs were included. The concepts of confidence and knowledge as they related to HFPS were used for the initial screening of the
literature. After initial review and analysis of the articles, it became clear
that several other concepts were worth examining: value, realism, stress,
and knowledge transfer. All articles were reviewed again to determine
whether they addressed these concepts. A concept that emerged in the
new search was learner satisfaction.
Excluded were articles on HFPS used for the education, training, or
orientation of nurses rather than nursing students, as were those limited
to live patient simulation, computer simulation, and low-fidelity simulation; conference proceedings; and articles on the use of HFPS in graduate-level nursing education. No specific criteria were set for sample size.
High-fidelity patient simulation refers to predeveloped patient scenarios utilizing computerized manikins that respond to intervention by
providing instant feedback. Since fidelity refers to the realism of the simulation, high-fidelity patient simulation is currently the highest level of
realism offered with patient simulation. Low-fidelity patient simulation
refers to individual manikin parts that are used simply as task trainers
to teach students specific psychomotor skills. Medium (or intermediate)-fidelity patient simulation uses manikins that can be somewhat
computerized; these offer opportunities to practice specific psychomotor skills but lack the complexity and realism of patient scenarios.
TERMINOLOGY
The term patient simulation has been used
throughout the nursing literature with a variety of meanings. In earlier
literature, patient simulation referred to anything from people acting the
role of an ill patient to computer software simulation to low- and medium-fidelity simulators. Most recently, the term has been used interchangeably with high-fidelity patient simulation. Another term used interchangeably with high-fidelity patient simulation is human patient simulation; many of the studies in this review used this last term.
It is interesting to note that although all of the studies in this review
utilized HFPS, many of the studies did not use the term high-fidelity
patient simulation, or another simulation term was used in the title. One
study referred to intermediate-fidelity simulation in the title (Alinier,
Hunt, Gordon, & Harwood, 2006), but the researchers description of
the study suggests that HFPS was used. For the purpose of this review,
patient simulation refers to high-fidelity patient simulation conducted
using realistic scenarios with a high-fidelity manikin.
Results and Review Process The search using the term patient

simulation yielded 323 articles in CINAHL; 1,366 articles in PubMed; and

214 articles in ERIC. A search using the terms patient simulation AND
nursing education yielded 36 articles in CINAHL; 117 articles in PubMed;
and 23 articles in ERIC. Of these, five articles met inclusion criteria. The
final search of the terms high-fidelity patient simulation AND nursing education yielded five articles in CINAHL; 19 articles in PubMed; and no articles in ERIC. A total of four articles from this search were used in this
integrative review.
The remaining articles used were obtained through the ancestry
search. The search in Dissertation Abstracts yielded one article that was
included in the integrative review.The other dissertation used was found
in Google Scholar. An updated search of the literature was conducted in

3 8 N u r s i n g E d u c a t i o n Pe r s p e c t i v e s

H I G H - F I D E L I T Y PAT I E N T S I M U L AT I O N

November 2010 using all of the aforementioned methods. This update

yielded six additional articles for use in this review.
A total of 24 articles were reviewed. The data from the articles were
placed in a matrix constructed in Microsoft Excel.The matrix was examined for various concepts related to HFPS. These concepts were coded
and listed in a chart for further synthesis. The concepts that emerged
from the literature include confidence, knowledge, knowledge transfer, value,
realism, stress, and learner satisfaction.
Google Scholar was also explored. The only articles found that were
not in any of the other database searches were a dissertation and articles in Clinical Simulation in Nursing. Review of abstracts in this journal on
the International Nursing Association for Clinical Simulation and
Learning (INACSL) website revealed a potential eight articles. It is interesting to note that access to these articles was limited to members of
INACSL and did not show up in any database search. Since the initial
review of literature, this journal has been made available to nonmembers and can be found in database searches. There may be studies that
are unpublished due to the recent interest and proliferation of HFPS.
Many of the concepts that emerged from this review
touched on the effects of HFPS on confidence and knowledge. Others
included knowledge transfer, value, realism, and stress.
C O N F I D E N C E Many of the articles discussed the use of HFPS
in providing a safe environment for students to make mistakes. However,
findings on confidence were mixed, despite the fact that HFPS is frequently touted as increasing students confidence. Johnson, Zerwic, and
Theis (1999) reported that as students familiarized themselves with clinical situations, their confidence in handling such situations increased.
Abdo and Ravert (2006) reported an increase in students confidence after their HFPS experience. In studies by both Bearnson and
Wiker (2005) and Burns, ODonnell, and Artman (2010), students
reported that confidence in their skills increased after HFPS. Results
from Kuznars study (2007) showed that students believed HFPS
improved their confidence. Smith and Roehrs (2009) found that students were self-confident based on their HFPS experience. Further, they
reported that design characteristics of the HFPS, specifically, clear objectives and a challenging experience, significantly correlated with satisfaction and self-confidence. In the 2006 NLN study, students exposed to
HFPS reported greater confidence in their ability to care for the type of
patient used in the simulation than students not exposed (Jeffries &
Rizzolo, 2006). Conversely, Feingold, Calaluce, and Kallen (2004) found
that a majority of students did not perceive HFPS as increasing their
confidence. In other studies, there was no significant difference in confidence between students who participated in HFPS and students who
did not participate (Alinier, Hunt, & Gordon, 2004; Alinier et al., 2006;
Blum, Borglund, & Parcells, 2010).
When there is a reported increase in confidence after HFPS that is
not then measured in a clinical setting, the student may perceive an
increase in confidence due to being in a controlled, supervised setting
where he or she can do no harm (Rockstraw, 2006). Perhaps the
increase of confidence is not realized until the student experiences a
real situation like the one in the simulation. There is little research that
examined whether confidence gained in HFPS was transferred to the
clinical setting. The student reporting an increase in confidence after
HFPS only is speculating; will confidence and knowledge gained during a
simulation apply to the clinical arena? More research about the transfer-

Discussion

TEACHING WITH TECHNOLOGY

ability of the simulation experience into the clinical setting, specifically

regarding confidence, is needed.
KNOWLEDGE Overall, students reported an increase in knowledge
after the HFPS experience (Alinier et al., 2004; Radhakrishnan, Roche, &
Cunningham, 2007). One study showed that HFPS used as a substitute
for one day of clinical experience with third-year nursing students
increased their knowledge of medication effects and responses
(Bearnson & Wiker, 2005). Another study indicated that when HFPS was
used in addition to traditional lectures with first-year nursing students,
most showed a significant gain in knowledge (Burns et al., 2010).
Dillard et al. (2009) examined students perceptions of the degree
they felt they understood the learning objectives of a HFPS. Students
indicated that they either mostly got the concept or totally got the
concept of all the learning objectives for the simulation.
Hoffman, ODonnell, and Kim (2007) used the Basic Knowledge
Assessment Tool-6 to measure improvement of knowledge in senior
nursing students after seven weeks of HFPS and seven weeks of a traditional clinical experience. They found significantly improved scores in six
of eight subscales; the two subscales that did not show significant
improvement assessed issues not addressed in the HFPS. More research
that compares knowledge gained in traditional clinical settings and simulated settings is needed.
Schumacher (2004) measured learning outcomes and critical-thinking abilities in junior nursing students using a customized Health
Education Systems, Inc. exam. This study revealed a significant increase
in knowledge and critical thinking when simulation or a combination of
simulation and classroom instruction were used.Two studies did not find
that knowledge increased after use of HFPS, however. Kardong-Edgren,
Anderson, & Michaels (2007) divided 14 students into three groups
lecture only, lecture and low-fidelity patient simulation, and lecture and
HFPS and found no significant difference in students posttest scores.
Limitations included a small sample size, the use of a convenience sample, and simulation not being examined apart from lecture. Also, Schlairet
and Pollock (2010) found no difference in knowledge acquisition among
74 students exposed to a traditional clinical experience and HFPS.
KNOWLEDGE TRANS FER Several studies examining the transfer
of knowledge gained from HFPS into the clinical setting had mixed
results. Abdo and Ravert (2006) found that 100 percent of the students
believed that their HFPS experience would benefit them in the clinical
setting. Conversely, another study showed that slightly less than half of
the students in the study thought that knowledge gained in HFPS would
transfer to the clinical setting (Feingold et al., 2004).
VALUE Students perceptions of the value of HFPS were measured
in several studies. Abdo and Ravert (2006) found that 95 percent of
students found it valuable, especially as it related to clinical decisionmaking. Feingold et al. (2004) reported that a majority of students
found HFPS to be a valuable learning tool. The majority of students in
a study by Wotton, Davis, Button, and Kelton (2010) felt that simulation
showed the usefulness of what they were learning and viewed debriefing as an important component of HFPS.
REA LISM Realism in HFPS was studied from various angles.
Ninety-six percent of students in Abdo and Raverts study (2006)
about students perceptions of HFPS agreed that the simulation was
realistic and that it recreated real-life patient situations. The majority
of the students who commented on realism in the 2006 study by
Bremner, Aduddell, Bennet, and VanGeest and the 2004 study by

H I G H - F I D E L I T Y PAT I E N T S I M U L AT I O N

Feingold et al. thought the HFPS experience was realistic.

Several studies examined students perceptions of the importance of
realism. Students in the NLN study (Jeffries & Rizzolo, 2006) rated realism as one of the most important features of HFPS. Also in that study,
students who participated in HFPS said that the experience was more
realistic than did students in groups that used simulation with a case
study or a static manikin. In a mixed-methods study by Cantrell, Meakim,
and Cash (2008), students placed high importance on the realism of the
simulation as a learning experience.
S TRES S Several studies examining the stress levels of students
working in a simulated environment produced inconsistent results. In a
British study, Alinier et al. (2004) found that there was no difference in
perceived stress between two groups of students; one group had one
exposure to HFPS, and the other had two exposures. In a later study
(Alinier et al., 2006), these researchers again demonstrated no difference between the groups. The second study included 99 students in the
sample; the earlier study had 67 students.
Bremner et al. (2006) found that fewer than half of the students in
their study said that HFPS relieved some of the stress on their first clinical day. Students in Morrison and Catanzaros study (2010) reported
feeling overwhelmed and anxious about how to respond during a simulated public-health emergency.
OTHER ISS UES Schools of nursing are beginning to investigate
issues of patient safety using simulation. Gantt and Webb-Corbett
(2010) reported that during simulation, students did not satisfactorily
perform hand hygiene or patient identification 61 percent of the time
and only 38 percent of the time after instruction. Missing from the literature, perhaps because HFPS has not been used long enough for all outcomes to be measured, are studies on the transfer of knowledge from
HFPS after graduation, the effectiveness of teaching strategies such as
debriefing and videotaping during the use of HFPS, and the cost-effectiveness of HFPS in nursing education.
One study examined student satisfaction with HFPS according to
learning style. Fountain and Alfred (2009) found that students who were
identified as having social and solitary learning styles were significantly
correlated with satisfaction with learning during HFPS. Student satisfaction was reported after a HFPS and significantly correlated to both
learning objectives and an appropriately challenging simulation (Smith &
Roehrs, 2009).
Implications for Research It is evident that more study on HFPS in

nursing education is needed, especially in the areas of communication

among participants in simulation, feedback and support given during and
after simulation, and student satisfaction. Also, continued research
efforts are needed in the following areas:
New theories and models for HFPS
The cost-effectiveness of various types of fidelity in simulation
Students knowledge acquisition through HFPS, as compared with
traditional clinical experience
The stress of working in simulated clinical environments, as
compared with real clinical settings
The transfer of knowledge when students become new nurses
The effect of various teaching strategies involved with HFPS,
including debriefing and videotaping
Students confidence in clinical experiences after being
exposed to HFPS

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The quality of debriefing after HFPS

The effectiveness of HFPS on students clinical judgment

H I G H - F I D E L I T Y PAT I E N T S I M U L AT I O N

environment, nursing students must be educated with the most realistic technologies available. HFPS might just change the face of nursing education. NLN

Conclusion This review of the literature found that HFPS benefits

nursing students in terms of knowledge, value, and realism. Further

research will determine whether its increased use is warranted,
especially in terms of whether benefits outweigh costs. But because
nurses must be prepared to work in an exceedingly complex care
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4 0 N ursin g Edu cation Perspectives

About the Author Amy Weaver, MSN, RN, ACNS-BC, an instructor in

the Department of Nursing at Youngstown State University,Youngstown, Ohio,
is a doctoral candidate in the Villanova University PhD in Nursing Program.
Contact her at aweaver@ysu.edu.

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