Teaching and Learning in Nursing (2015) xx, xxx–xxx

www.jtln.org

Large Group Simulation: Using Combined Teaching

Strategies to Connect Classroom and Clinical Learning1
Susan M. Moyer MSN, RN, CNE⁎
Reading Area Community College, Division of Health Professions, 10 South Second Street, Reading, PA, 19603, USA

KEYWORDS: Abstract
Large group simulation; A growing disconnect exists between what students learn in the classroom and how they use nursing
Unfolding case studies; concepts to provide safe and effective care in a clinical setting. The purpose of this article is to share a
Low-fidelity simulation; large group simulation teaching and learning strategy that combines unfolding case studies, low-fidelity
PowerPoint®; simulation, and PowerPoint® to facilitate active learning and the integration of classroom and clinical
Active learning; learning in an associate degree nursing program.
Teaching and © 2015 Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.
learning strategy

1. Introduction combines unfolding case studies, low-fidelity simulation,

The Carnegie report of nursing education reported nurses
are undereducated for the demands of present-day nursing
practice (Benner, Sutphen, Leonard, & Day, 2010). A
growing disconnect exists between what students learn in the
classroom and how they use the knowledge to think critically
and problem solve effectively to provide safe and competent
patient care. The Carnegie report recommends providing
students with more opportunities to practice the integration
of professional nursing knowledge and skills into the care
of increasingly complex patients (Benner et al., 2010).
This requires educators to shift from teacher-centered,
lecture-focused classrooms to student-centered, active learn-
ing environments that are cost-effective and efficient and
emphasize collaboration, critical thinking, and decision-
making skills (Day, 2011; Della Ratta, 2015; West, Usher, &
Delaney, 2012). The purpose of this article is to share a large
group simulation teaching and learning strategy that
1
No grant support; no financial support; no previous presentation
⁎ Corresponding author. Tel.: +1 610 372 4721x5432.
E-mail address: smoyer@racc.edu.
and PowerPoint® to facilitate active learning and the integration
of classroom and clinical learning in an associate degree
nursing program.
2. Active Learning in Nursing Education
Nurse educators have the formidable task of teaching
expanding nursing knowledge, psychomotor skills, and
professionalism to diverse student populations in order to
prepare them for practice in dynamic health care environ-
ments. In addition, a growing number of students are
requesting interactive educational experiences where oppor-
tunities are available to practice the application of theoretical
concepts to clinical practice (Stanley & Dougherty, 2010).
When nurse educators use active learning strategies to teach
content, students have opportunities to develop their critical
thinking, problem-solving, and reflection skills (Dewing,
2010). Active learning promotes student engagement and
improves learning, retention of material, and transfer of
knowledge and skills into practice (Dewing, 2010; Gleason
et al., 2011).

http://dx.doi.org/10.1016/j.teln.2016.01.002
1557-3087/© 2015 Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.
2 S.M. Moyer
Despite the evidence that students learn better when they are
engaged in the learning process, nursing education continues to
focus on content where faculty rely on traditional lecture and
PowerPoint® methods to implement content-loaded, time-
constrained curricula (Day, 2011; Della Ratta, 2015). This
results in passive student learning, and students have few, if any,
classroom opportunities to practice applying nursing concepts
learned to situations they will encounter in clinical practice.
3. Background
A review of student course evaluations from a small urban
community college nursing program revealed student requests
for increased interactive classroom learning experiences to
practice the application of nursing knowledge in simulated
clinical situations. In an effort to meet the needs of the students
in the nursing program and incorporate recommendations from
the Carnegie report (Benner et al., 2010), I developed and
implemented a large group classroom simulation active
learning strategy to teach freshman nursing students in an
associate degree nursing program. The strategy is practical and
combines common teaching and learning modalities: unfolding
case studies, low-fidelity simulation, and PowerPoint®.
Various studies have detailed the effectiveness of the use of
these strategies independently or paired; however, information
regarding the concurrent use of all three of these methods to
organize a large group simulation is not evident in the literature.
4. Teaching and Learning Strategies
4.1. Unfolding Case Studies
The use of unfolding case studies is a popular interactive
teaching and learning strategy. Unfolding case studies
present a clinical scenario of a patient whose condition or
disposition changes over time. Utilization of this strategy
assists students to develop critical thinking and problem-
solving skills because data on the patient is limited and
revealed only as the case unfolds (Day, 2011; Reese, 2011;
Shellenbarger & Robb, 2015). This provides a sense of
unpredictability and challenges students to use learned
classroom theory to prioritize care and make decisions
based on limited patient information, similar to the reality of
actual nursing practice (Shellenbarger & Robb, 2015).
Unfolding case studies are flexible and can be individualized
to highlight specific concepts or areas of nursing, and they can
be designed to accommodate large groups of students within
various types and levels of nursing courses (Day, 2011).
4.2. Low-Fidelity Simulation
Technology continues to expand in both health care and
nursing education. In a review of the literature by Cant and
Cooper (2010), twelve studies identified the use of simulation
as a valid teaching and learning strategy. Simulation
experiences can be low-fidelity to high-fidelity based on the
technology involved and degree they match reality (Cant &
Cooper, 2010). Literature reveals that simulation has a positive
impact on student learning and assists students to integrate
classroom theory and clinical application (Lasater, Johnson,
Ravert, & Rink, 2014; Yuan, Williams, & Fang, 2012).
Simulation provides real-life interactive experiences, al-
though, it can be time intensive and expensive to implement and
utilize in nursing programs. Barriers to simulation include cost,
faculty and facility resources, and fear of technology (Howard,
Ross, Mitchell, & Nelson, 2010; Kisner & Johnson-Anderson,
2010); however, not all simulation modalities require the same
resources. Low-fidelity simulation is an example of a
cost-effective, low-resource type of simulation that can be
effective in promoting student learning (Sharpnack & Madigan,
2012). This simulation modality uses common, inexpensive
static mannequins. It lacks the interactive capability found in
high-fidelity human patient simulators; yet, this modality does
provide students with opportunities to practice skills and
transfer learning to practice (Lasater et al., 2014; Sharpnack &
Madigan, 2012; Yuan et al., 2012). The literature reveals that
students are satisfied learning from simulation that involves any
degree of fidelity (Tosterud, Hedelin, & Hall-Lord, 2013)
which that supports the use of low-fidelity simulation in nursing
programs where resources may be limited.
4.3. PowerPoint®
PowerPoint® is an example of presentation software that
uses projected slides to present visual and auditory content.
Students evaluate the use of PowerPoint® positively, and
research suggests that this technology increases attention
span and interest; engages listening, thinking, and participa-
tion; promotes learning; and enhances comprehension of
course material (Hill, Arford, Lubitow, & Smollin, 2012).
The literature cites many benefits of using PowerPoint®;
yet, educators continue to be challenged to use this
technology in ways that stimulate students to respond and
participate actively in classroom learning. By incorporating
PowerPoint® with alternative active learning strategies,
educators use this technology most efficiently to improve
classroom learning experiences (Hill et al., 2012).
The use of unfolding case studies, low-fidelity simulation,
and PowerPoint® as instructional strategies is not new; yet,
combining these modalities increases student engagement and
provides opportunities for teaching to a variety of learning
styles. Combining strategies encourages active learning in the
classroom and is one way to assist large groups of students in
connecting learned nursing concepts to clinical application.
5. Getting Started
I developed an unfolding case study that incorporated
low-fidelity simulation and PowerPoint® to teach associate
LARGE GROUP SIMULATION
degree nursing students. This combined teaching strategy
was used in a freshman nursing course where the course
objectives focused on fundamental nursing concepts and
skills. This course consisted of 49 first semester freshman
nursing students who were completing long-term care
clinical rotations. Upon admission to this course, students
were required to complete general education courses
including anatomy and physiology.
I used a template by Page, Kowlowitz, and Alden (2010)
to develop the unfolding case studies, which started with
topic selection. I chose to focus the unfolding case study on
the care of an acute care patient because students were
preparing to begin acute care clinical and many of them were
inexperienced in caring for hospitalized patients.
Next, I identified learning objectives and determined key
nursing concepts that would be incorporated into the case
study (Page et al., 2010). Learning objectives for the case
focused on the use of active learning strategies to facilitate
the care and management of an acute care patient. The key
concepts focused on fundamental nursing knowledge and
skills such as application of the nursing process, communi-
cation, and documentation.
When I began outline development, I remained cognizant
of the time frame for case study implementation (Page et al.,
2010). I had 2 hours to complete the strategy, which included
precase study instructions and group work, implementation
of the unfolding case study, and postcase study debriefing.
I created the story and characters utilizing a combination of
unfolding case study templates from the National League for
Nursing Web site (“Advancing Care Excellence for Seniors
(ACES),” n.d.), Internet resources, and past clinical experiences
for the development of the story (Page et al., 2010). Characters
present in the case study included an elderly patient, a family
member, and registered nursing staff. I selected these characters
because the students were completing long-term care clinical
rotations and were most familiar with the care of elderly clients.
In addition, the interaction with a patient and a family member
required utilization of learned therapeutic communication skills.
I began writing the case to depict an acute care patient
experiencing a change in condition. I designed the case study
to represent a newly admitted elderly patient who came from
home after experiencing confusion and a fall. As the case
unfolds, the patient becomes more confused and experiences
respiratory issues. Students need to think critically and apply
nursing process skills, prioritize, and communicate effectively
to implement a plan that will improve the patient outcomes.
A variation to this teaching and learning strategy, as
compared to other modalities, is that I divided the class into
student groups who were each responsible for different
aspects of the case study. This created a large group
simulation experience that encouraged synchronous active
learning among all students in the class and enabled the case
study to unfold as each student group performed or discussed
their assigned parts. To accomplish this, I wrote the case
study from start to finish and then developed group roles and
activities that were performed at varying points throughout
3
the case study (Table 1). I focused the group roles on aspects
of key nursing concepts, and I planned to discuss each role
with the class prior to beginning the case study.
In addition to using group work to unfold the case, I also
utilized a low-fidelity mannequin and PowerPoint® to
supplement various aspects of the case study. I incorporated
these instructional strategies to assist in simulating a more
realistic clinical scenario and to capture diverse learning
styles. The mannequin was designed to resemble the acute
care patient in the case study and was present on a litter in the
front of the classroom. This enabled students to connect the
patient in the case study to the mannequin in the classroom and
provided students with an opportunity to perform assessments
and skills required in the case study. Laboratory faculty
assisted in outfitting the mannequin in necessary equipment
and provided additional supplies required in the case such as a
stocked medication cart and nasal cannula. I created a patient
chart using templates from the National League for Nursing
Web site (ACES, n.d.), and this chart was distributed to all
student groups. It contained pertinent health care provider
(HCP) notes, orders, medical and surgical history, laboratory
and diagnostic results, and a medication record.
I incorporated PowerPoint® into the unfolding case study
to assist in providing visual and auditory aspects of the
scenario. I designed the slides to display Internet images of
an elderly patient that were embedded with prerecorded,
self-made audio clips. The audio clips included the patient
talking or making requests, of family members who were
concerned about their loved one, and of nursing staff
providing shift reports. I forwarded the slides and cued the
audio to play at specified times throughout the case study.
The addition of audio provided students with the opportunity
to hear the case study unfold and also required students to
pay attention and listen for details throughout the scenario.
After the case study was written and the group roles were
prepared, I developed an instructor guide to accompany the
unfolding case study. The instructor guide included audio scripts,
assessment results, and prompts for advancing slides, presenting
new orders, and facilitating group participation. It also included
reminders to highlight key points and priority concerns throughout
the case study. I used this guide to assist me in keeping the case
study on track and moving forward methodically. An example of
part of the instructor guide is displayed in Table 2.
Lastly, I reviewed the unfolding case study to ensure that it was
complete, logical, realistic, and included the necessary informa-
tion needed to make clinical decisions (Page et al., 2010). I
reexamined the case study to be sure that it included relevant
clinical and contextual information, that activities to meet the
learning objectives were available, and that the level of content
was appropriate for the freshman students (Page et al., 2010).
6. Case Implementation
I implemented this large group simulation experience
with a freshman nursing class (N = 49). I determined the
4 S.M. Moyer

Table 1 Group roles and associated activities for each role within the unfolding case study
Group role
1. Observer group
2. Assessment group
3. Lab analysis group
4. Medication group
5. Nursing diagnosis group
6. Safety and client
education group
7. Documentation group
8. Reporting group
Associated group activities
• “Taking it all in”: Observing peer activities
• Assisting in critical thinking as needed
• Providing peer review and reflection at conclusion of case
• Complete organized head to toe assessments. Review orders to determine frequency of assessments
• Perform actual skills on patient/mannequin. Use the preparation time to familiarize group with the
mannequin and equipment
• Use cue cards to report assessment findings
• Use therapeutic communication with patient and family
• Act on all new orders received
• Analyze available laboratory studies. Prepare to explain analysis of abnormal studies to peers
• Consider how the laboratories correlate with the HCP orders
• Research all medications and consider correlations between medical history, present illness, and
laboratory studies.
• Prepare to administer medications at assigned times. Review safe medication administration.
• Review intravenous infusion rate calculations.
• Review the definition, defining characteristics, etiology, and interventions for the following diagnostic
labels. You will share applicable nursing diagnoses as needed throughout case study
○ Risk for falls
○ Acute confusion
○ Ineffective breathing pattern
○ Impaired gas exchange
○ Impaired urinary elimination
○ Nutrition: less than body requirements
• Consider interventions for confused patients at risk for falls
• Review hospital safety measures
• Review the following client education topics:
○ Pain medicine and antibiotic use
○ Pneumonia
○ Hypertension
○ Influenza vaccination
• Draw flowsheets on board: Need nursing assessments, vital signs, intake and output record
• Chart all assessments, vital signs, and intake and output on white board throughout case study
• Review SBAR reporting.
• Record activities throughout the case study so that you are prepared to contact the HCP as needed in the
case
• Review shift reporting. Be prepared to share an end of shift report at the conclusion of the case study.

group role sizes based on enrolled students and the amount of
preparation required in each role. Students were randomly
assigned to one of the eight groups, and each group consisted
of approximately five to seven students.
I described the simulation experience and provided an
overview of the case study to the class (Table 3). All groups
also received a patient chart and an index card that explained
the roles and activities for each group as described in Table 2.
Students had 20–30 minutes to prepare their respective parts,
and I provided each group individualized instruction to aid in
their role preparation. Students were encouraged to observe
and assess the mannequin and use textbooks and group
collaboration to prepare parts.
Once the group preparation was complete, I began the
unfolding case study. Generally, the case study consisted of
PowerPoint® slides embedded with self-recorded audio of
the patient, staff, or family talking, which I cued to play at
varying times throughout the scenario. The slides pictured
the patient in 2-hour increments throughout the 0700–1900
day shift and also included other visual elements like a lunch
tray that assessed accuracy of intake measurement. The case
study unfolded depicting a decompensating patient
experiencing respiratory distress. Student groups had to
perform assessments, analyze data, communicate with the
HCP, initiate new orders, and prioritize care. I forwarded the
slides and prompted various groups to either perform skills
or share information on the area they were assigned when it
was relevant in the scenario. As the case unfolded, I assisted
students to perform ongoing analysis of assessment data and
to think critically about how to connect nursing knowledge to
LARGE GROUP SIMULATION 5

Table 2 Example of part of the instructor guide for the large group simulation experience
0800 Morning report completed; assessment group comes to front of class and prepares to care for mannequin/patient on litter
(FORWARD SLIDE): Slide pictures an elderly patient sitting in a hospital bed
Upon entering room, students should do the following:

• Wash hands, ID self and patient (play slide audio after students ID him)
• Audio Script: “Hi there, my name is J. Kirk and my date of birth is Sept. 24, 1938.
My daughter dropped me off here and I am not sure where I am…at the clinic or something?
Is it 2013? I feel okay but my daughter said I only ate a quarter of my breakfast.
She had to go to work or something. I think I need my pills…
I don’t know what they are but you can ask my daughter to look for them on the kitchen counter.
Where is Deena anyway? She never comes to see me.”
Assessment group should reveal:

• Assessment findings: All normal except client confused and lungs decreased bilaterally,
not taking deep breaths; has not voided since 0400
• Vital signs: 99°F-92-18-162/88; 96% on room air
Documentation group should do the following:

• Document breakfast intake, assessment data revealed

Facilitator: Critical thinking

• Ask class: Any initial concerns about intake? Any concerns about assessment data?
• Students should also want to review medications and laboratory results.
Laboratory analysis group presents:

• Explains abnormal results and correlation of results to medications and patient data
Medication group participates:

• Reviews 0800 medications at cart and provides explanations as to why the patient is receiving the medications.
• Reviews current health provider orders
• Facilitator may also question if any medications are missing.
• Group proceeds to administer medications
Diagnosis group participates:

• Provides class with relevant nursing diagnoses based on current data and explains why these diagnoses are pertinent.
• Facilitator assists class in initial care plan development

the patient scenario. I also provided discussion points at 7. Case Evaluation

strategic times in the case study to help students identify
nursing priorities and the importance of making accurate
clinical judgments. I continued to prompt specific groups to
participate until the scenario was completed. The case study
took approximately 50–60 minutes to unfold and concluded
with the patient in stable condition.
I provided approximately 30 minutes of debriefing time at
the conclusion of the simulation experience. This helped
students explore and evaluate their decision-making skills
and encouraged students to reflect on key concepts and the
learning experience (Kisner & Johnson-Anderson, 2010;
Page et al., 2010). At the conclusion, students were asked to
evaluate the teaching and learning strategy, and many
students openly voiced positive feedback regarding the
learning experience.
I received approval from the institutional review board to
collect data on the effectiveness of the teaching and learning
strategy. I evaluated the large group simulation experience by
developing a 17-item Likert scale survey, and completion of
the survey was considered as informed consent. Students were
asked to rate various aspects of the strategy and their
perceptions of the value of the simulation experience. The
class consisted of 49 students, and 46 students completed the
survey (n = 46). The Likert scale ranged from 1 to 5 where 1
represented strongly disagree to 5 representing strongly agree.
Overall, students evaluated the experience positively, rating most
aspects of the experience at a mean score of 4.0 or greater (Table 4).
Qualitative data obtained from the survey also indicated positive
student perceptions regarding the simulation experience (Table 5).
6 S.M. Moyer

Table 3 Overview of unfolding case study provided to students
Instructor reviews at start:
Mr. J. Kirk, 76 years old, has been admitted to the medical–surgical
unit for evaluation after a fall. No fractures have been identified.
Mr. Kirk's family notes that he has been experiencing increasing
difficulty with his memory and he has not taken medications
properly in the days prior to admission.
You are assigned to Mr. Kirk during the 0700–1900 day shift.
education were not emphasized to the same degree as other
areas in the case study. In future application of this strategy, I
recommend providing written examples of shift and SBAR
reports, increased emphasis on the national patient safety
goals, and increased performance time for patient education.

8. Lessons Learned
Implementing a large group simulation experience for the
first time required a considerable amount of preparation on
my part. Developing a detailed unfolding case study and
incorporating PowerPoint® embedded with self-recorded
audio clips was time consuming. Developing group roles and
activities and inserting them into the case study required
additional thought and creativity. Managing the simulation
was most challenging as I operated the PowerPoint® and
audio while facilitating the application of the nursing process
and integration of nursing concepts and clinical practice. If
possible, the assistance of one or more faculty facilitators
may be helpful.
The survey results revealed reporting; situation, back-
ground, assessment, recommendation (SBAR); patient
safety; and patient education as weak areas. It is plausible
that students felt inexperienced at applying reporting and
SBAR communication skills, especially in the freshman
year, as the skill is taught, but its application is limited. It is
also conceivable that the areas of patient safety and patient
9. Summary
Implementing a large group simulation using unfolding
case studies, low-fidelity simulation, and PowerPoint®
concurrently is a unique approach to engage students and
provide active learning in the classroom. Combining these
three instructional modalities provides opportunities for an
entire class to integrate nursing concepts and clinical
practice. This strategy can be used to address a variety of
learning styles and can be used with various student
populations, group sizes, concepts, and courses.
Initial results of this large group simulation experience are
encouraging; yet, further evaluation of this teaching strategy
is recommended to determine its continued effectiveness as a
learning tool and its impact on student learning outcomes.
The use of unfolding case studies, low-fidelity simulation,
and PowerPoint® concurrently promotes active learning,
collaboration, problem solving, and the integration of
classroom and clinical learning. In doing so, students have
increased opportunities in the classroom setting to prepare
for the demands of the nursing profession that exist in the
clinical setting.

Table 4 Mean survey scores for large group simulation experience

Survey statement Mean score
1. I was an active participant in the unfolding case study. 4.0
2. The unfolding case study scenario was realistic. 4.2
3. The unfolding case study demonstrated an acute care patient. 4.3
4. The unfolding case study helped me to understand the nurse's role in caring for an acute care patient. 4.2
5. I was able to identify patient problems and determine appropriate nursing diagnoses. 4.0
6. I was able to analyze patient data and correlate it to the patient's problems. 4.1
7. I was able to review patient medications and correlate them to patient history and/or present problem. 4.0
8. I was able to analyze laboratory data and correlate it to patient history and/or present problem. 4.0
9. I was able to review HCP orders. 4.2
10. I was able to practice reporting. 3.5
11. I was able to practice SBAR communication. 3.2
12. I was able to review patient safety. 3.9
13. I was able to practice client education. 3.4
14. I was able to practice my critical thinking skills. 4.2
15. I was able to incorporate theory into hands-on practice. 4.0
16. This experience enabled me to identify areas of strength and areas that I feel I need more practice in. 4.1
17. This was a valuable experience, and I would recommend using this teaching/learning strategy again. 4.3
Note: Ratings based on 1–5, where 5 is the highest achievable score.
LARGE GROUP SIMULATION 7

Table 5 Qualitative student responses for large group simulation experience

• “Very creative and a fun hands on approach to learning”
• “I would really appreciate more activities such as this one as we progress through the course.”
• “I did not believe I would be able to demonstrate the theory I have been learning.
This exercise showed that I know more than I realize and gave me some confidence in my skills.”
• “I liked the simulation because it showed how fast paced acute care is as compared to long term care.
It is interesting to see how much knowledge we have learned in such a short amount of time.
I would highly recommend doing it next year.”
• “Very helpful and fun.”
• “I loved being part of the case study.
I was nervous to go in front of the class but once I went up I felt at ease and just focused on my task.
This was the first time that I can honestly say I began thinking more critically as a nursing student.
Thank you for adding this form of teaching and hopefully you will incorporate it for other student experiences.”
• “I enjoyed it and it was a great learning experience for those of us with no acute care experience.”

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