Determining the Value of Determining the Value of Simulation Training Simulation Training

Within Nurse Education: Within Nurse Education: A Literature Review A Literature Review

Sarah Sibley RN

Senior Nurse Educator

BMSC

Bristol Medical Simulation Bristol Medical Simulation Centre (BMSC)Centre (BMSC)

Situated in the UBHT Education Centre –

Purpose built centre with 3 simulation areas

IntroductionIntroduction

• The transition from classroom to clinical practice is reported as a time of fear and uncertainty among nursing students (Ham and O’Rourke, 2004 and Shepherd et al, 2007).

• Literature highlights the increasing challenges nurse educators face in preparing student nurses’ for the real world of nursing (Jefferies, 2005).

Effective

Innovative

Training methodsConsolidate

NursesLearning

Transition fromTheory to-

Practice

Regulatory bodies

Assess skillsStrengthen

competence

Enhance Overall Knowledge

&practice

Nurse TrainingNurse Training

• Variations in clinical opportunities during training• Increasing number of students vs. decreasing

clinical placements in UK• Variations in competence in communication,

administration of medicines & decision making (NMC, 2005)

• Nursing education challenged to develop nurse’s clinical/ non-clinical skills & competence to prepare them for real practice

Challenges for clinical nurse educatorsChallenges for clinical nurse educators

• The need to provide qualified nurses with opportunities to practice patient assessment and effective management skills when dealing with the critically ill patient (Parparella et al, 2004).

• Increasing pressure on acute hospital beds frequently results in increased dependency of ward based patients (Nunn 2004).

• ‘Comprehensive Critical Care’ (DoH, 2000)

• ‘An Acute Problem?’ (NCEPOD, 2005) reported nurses are still failing to recognise & act upon clinical indicators of critical illness and request prompt review of patients.

Simulation training… Simulation training…

• Well established in healthcare education becoming more & more common in nursing education.

• Clinical skills relevant to clinical practice can be taught and successfully mastered by trainees in a risk-free learning environment where errors can be allowed to occur (Paparella et al, 2004).

Simulation training…Simulation training…• A method to teach the

application of critical thinking skills, communication and team interactions (Nehring and Lashley, 2004).

• When scenario-based teaching is introduced it provides a key role in ‘training responses to high-risk, low-frequency clinical events’ (Nunn, 2004).

The rationale for the The rationale for the literature reviewliterature review

• Increasing need to validate the use of simulation training

• Evidence of simulation training effective in knowledge & skills transference?

• Does it deliver safer patient care?

The research questionThe research question The aim of this literature review was to determine whether

simulation training is an appropriate and affective teaching method to be used in nursing. The advantages and disadvantages of simulation were explored using three sub-questions:

1. Is simulation based training more effective than traditional teaching strategies used in nurse education?

2. Can simulated clinical experiences improve confidence and competence in nursing students and prepare them for real practice?

3. Can simulated-training improve interprofessional team performance and improve patient safety?

Limitations to literature reviewLimitations to literature review

• Much of the research material was medical based

• Some research was carried out by manufacturers of human patient simulators

Critical Review Critical Review Q1. Is simulation based training more effective than Q1. Is simulation based training more effective than traditional teaching strategies in nurse education?traditional teaching strategies in nurse education?

• Three quantitative research papers;– Jefferies et al, (2003)– Alinier et al (2006)– Shepherd et al

(2007)

Alinier, G., Hunt, B., Gordon, R. & Harwood, C. (2006) Alinier, G., Hunt, B., Gordon, R. & Harwood, C. (2006) Effectiveness of intermediate-fidelity simulation training Effectiveness of intermediate-fidelity simulation training

technology in undergraduate nursing education.technology in undergraduate nursing education. Journal of Advanced Nursing, Journal of Advanced Nursing, 54(3), 350-369.54(3), 350-369.

• Quantitative UK study • Aimed at determining the effect of simulation training

on nursing students’ clinical skills and competence• Volunteer undergraduate students (n=99) were

randomly allocated to either a control group or experimental,

• A pre-test/ post-test design was used using a 15 station Objective Structured Clinical Examination (OSCE).

• Experimental group exposed to simulation training as well as following their normal curriculum.

Findings ~Findings ~

• Results of the two groups for the second OSCE indicated the experimental group generally obtained higher marks than those in the control group (p<0.001)

• Researchers conclude that simulation is beneficial in nursing education if used appropriately– Students decide appropriate treatment & actions– Learn from mistakes & act on their own judgement

• Quantitative North American study • Compared the effectiveness of an interactive, multimedia CD-ROM

with traditional methods of teaching the skill of performing a 12 lead ECG.

• Randomised pre/ post-test experimental design to compare the two teaching methods, with a convenience sample of senior baccalaureate nursing students (n=77).

• Traditional method included a self-study module, a brief lecture & demonstration by instructor and hands-on experience using a manikin and a real 12-lead ECG machine.

• The simulation method covered the same content using an interactive CD-ROM embedded with virtual reality technology and supplemented by the self-study module.

• Objective observation measured the students ability to perform an ECG comparing the effectiveness of the two teaching methods.

Jefferies, P. R., Woolf, S. & Linde, B. (2003) Jefferies, P. R., Woolf, S. & Linde, B. (2003) Technology-Technology-based vs. Traditional Instruction: A Comparison of Two based vs. Traditional Instruction: A Comparison of Two Methods for Teaching the Skill of Performing a 12-Lead ECG.Methods for Teaching the Skill of Performing a 12-Lead ECG. Nursing Education Perspectives,Nursing Education Perspectives, 24(2), 70-74. 24(2), 70-74.

Findings ~Findings ~• Five-item Likert response scale evaluation of the study

showed positive effects on students learning outcomes and behaviours

• Results showed improvement for both groups from pretest to posttest were statistically significant (p<0.0001).

• No significant difference by group on pretest, posttest or improvement scores.

• No difference between groups on the consistency in performing a 12-lead ECG and found both groups performed equally well with the skill.

• However the study concludes the use of a CD-ROM may be an excellent and efficient alternative to traditional teaching methods

Shepherd, I. A., Kelly, C. M., Skene, F. M. & White, K. T. Shepherd, I. A., Kelly, C. M., Skene, F. M. & White, K. T. (2007). (2007). Enhancing Graduate Nurses’ Health Assessment Enhancing Graduate Nurses’ Health Assessment

Knowledge and Skills Using Low-Fidelity Adult Human Knowledge and Skills Using Low-Fidelity Adult Human Simulation.Simulation. Simulation in Healthcare, Simulation in Healthcare, 2(1),2(1), 16-24.16-24.

• Quantitative Australian study • Investigated the impact of three learning interventions

on Graduate nurses’ health assessment and skills• A convenience sample of nurses’ (n=74)• Random allocation to three groups (1: self-directed

learning package (SDLP) only; 2: SDLP plus two scenario based PowerPoint WORKSHOPS; and 3: SDLP plus two simulation education sessions)

• Following the training students completed a systematic patient assessment upon a manikin then scored against a checklist of relevant responses.

Findings ~Findings ~

• Their results showed the simulation group performed significantly higher than those in the other two groups (p<0.0001)

• Concluded simulation could play a key role in allowing students to develop clinical reasoning decision-making skills within a safe learning environment

• Educational activities involving simulation are more effective than traditional teaching methods

Summary Summary • A combination of

simulation training and a relevant educational framework offers a significant alternative over traditional teaching methods in preparing nurses’ for practice.

• Practice systematic patient assessments, critical thinking, clinical reasoning and decision-making skills.

Critical ReviewCritical ReviewQ2. Can simulated clinical experiences improve Q2. Can simulated clinical experiences improve

confidence and competence in nursing students and confidence and competence in nursing students and prepare them for real practice?prepare them for real practice?

• Novice nurses’ often lack confidence, and with that competence, to provide safe and effective care (Schoening et al, 2006).

• Studies by Bremner et al, (2006) and Schoening et al, (2006) use quantitative and qualitative research

Bremner, M. N., Aduddell, K., Bennett, D. N. & Bremner, M. N., Aduddell, K., Bennett, D. N. & VanGeest, J. B. (2006) VanGeest, J. B. (2006) The Use of Human Patient The Use of Human Patient

Simulators: Best Practices With Novice Nursing Simulators: Best Practices With Novice Nursing StudentsStudents. . Nurse Educator, Nurse Educator, 31(4), 170-174.31(4), 170-174.

• North American triangulation study using quantitative and qualitative analysis of students experiences in simulation.

• A convenience sample (n = 56) of novice students’ in a baccalaureate programme completed a head to toe assessment using the human patient simulator.

• Following the learning activity, students completed a 2-part questionnaire about their experiences.

FindingsFindings

• Qualitative data analysis showed students’ found simulation a positive experience.

• 61% felt the experience gave them increased confidence

• Identified themes were: teaching/ learning utility; realism; limitations; confidence/ comfort

Schoening, A. M., Sittner, B. J. & Todd, M. J. (2006). Schoening, A. M., Sittner, B. J. & Todd, M. J. (2006). Simulated Simulated Clinical Experience: Nursing Students’ Perceptions and the Clinical Experience: Nursing Students’ Perceptions and the

Educators’ Role.Educators’ Role. Nurse Educator,Nurse Educator, 31(6), 253-258. 31(6), 253-258.

• North American study used both quantitative and qualitative methodologies to examine nursing students’ perceptions of the simulated clinical experience (SCE) and the role of the educator.

• Non-experimental pilot evaluation study to identify and refine simulation training and gain insight of students’ perceptions of the experience.

• A convenience sample (n = 60) of baccalaureate nursing students’ completed an evaluation following a SCE.

• Students in groups of 7-8 were randomly assigned to roles• Student journals also provided descriptive information of

the students’ experience.

FindingsFindings

• Results indicate students felt the Simulated Clinical Experience to be an effective teaching method.

• Identified themes were: skills, hands-on learning and practice; confidence, self-efficacy and non-threatening environment; critical thinking, realism, knowledge, review and decision-making.

SummarySummary

• Both researchers conclude the data analyses indicated students increased confidence in the clinical setting following the SCE.

Critical ReviewCritical ReviewQ3. Can simulated-training improve interprofessional Q3. Can simulated-training improve interprofessional

team performance and improve patient safety?team performance and improve patient safety?

• Three research studies addressed the question of whether simulation-based training can improve clinical team performance.

• Ker et al, (2003)• Shapiro et al (2004)• DeVita et al, (2005)

Ker, J., Mole, L. & Bradley, P. (2003) Ker, J., Mole, L. & Bradley, P. (2003) Early introduction Early introduction to interprofessional learning: a simulated ward to interprofessional learning: a simulated ward

environment.environment. Medical Education, Medical Education, 37, 248-255.37, 248-255.

• UK Study used a qualitative research approach to evaluate a interprofessional simulated ward environment.

• A convenience sample (n = 151) of nursing and medical students participated in the pilot exercise

• Students were allocated to teams of nursing and medical students and required to take charge of a ward bay of simulated patients for an hour.

• Teams were observed by faculty members to help set formative assessment criteria and learning objectives

• Participants also completed a semi-structured evaluation questionnaire.

FindingsFindings

• Themes identified were: educational environment, organisational issues, interprofessional aspects and communication.

• Evaluation participant questionnaires reported the exercise was received positively.

Shapiro, M. J., Morey, J. C., Small, S. D., Langford, C. J. Shapiro, M. J., Morey, J. C., Small, S. D., Langford, C. J. Kaylor, C. J., Jagminas, l., Suner, S., Salisbury, L., Simon, R. Kaylor, C. J., Jagminas, l., Suner, S., Salisbury, L., Simon, R. & Jay, G. D. (2004)& Jay, G. D. (2004) Simulation based teamwork training for Simulation based teamwork training for emergency department staff: does it improve clinical team emergency department staff: does it improve clinical team performance when added to an existing didactic teamwork performance when added to an existing didactic teamwork

curriculum?curriculum? Quality and Safety in Health Care,Quality and Safety in Health Care, 13, 417-421. 13, 417-421.

• North American single crossover, prospective, blinded and controlled observational study to determine if simulation based team training can improve clinical team performance.

• Small sample (n = 20) of nurses’ and emergency department physicians randomly selected from a larger convenience sample (n = 152).

• Following a didactic training on an emergency team coordination course (ETCC), emergency department staff randomly allocated into teams of experimental and comparison groups.

• The experimental group received simulation training following the ETCC course

• Teams were observed before and after intervention.

FindingsFindings

• No statistical significance in the pretest scores between either group.

• Results from the clinical observations demonstrated the experimental group showed improvement after simulation (p = 0.07).

• Unfamiliar environment can distract some participants from the goal of practicing teamwork skills (Shapiro et al, (2004).

DeVita, M. A., Schaefer, J. L,. Wang, H. & Dongilli, T. (2005) DeVita, M. A., Schaefer, J. L,. Wang, H. & Dongilli, T. (2005) Improving medical emergency team (MET) performance Improving medical emergency team (MET) performance

using a novel curriculum and a computerized human patient using a novel curriculum and a computerized human patient simulator.simulator. Quality and Safety in Health Care, Quality and Safety in Health Care, 14, 326-331.14, 326-331.

• North American study to evaluated a crisis team-training course, which used human simulation training in developing multidisciplinary team skills and improving medical emergency team (MET).

• Pretest and structured observation to collect data during their study.

• Convenience sample (n = 138) teams of critical care nurses, physician & respiratory therapists took part in three out of five simulated crisis scenarios Scenario outcome measures were set to determine the successful crisis management.

• Secondary outcomes measured crisis task completion rate (TCR), which was a set of 29 tasks defined for each scenario.

FindingsFindings

• Results showed overall simulator ‘survival’ improved from 0% to 90% across scenarios (p = 0.002).

• Post hoc analysis revealed most improvement observed between first and second sessions (p = 0.0014).

• There was statistically significant improvement found with mean analysis of the TCR scores (p < 0.001).

SummarySummary

• Simulation training has a positive impact on interprofessional training and could be effective in reducing medical error

• SCE Allow participants to focus on skills, organisation and problem solving within a team, rather than individually learning facts in isolation

Implications for nursing Implications for nursing practice and education practice and education

• Simulation training can be applied to all levels of experience, from novice to expert.

• There’s also evidence that simulation training can be used for staff development and refresh knowledge and skills, helping to reduce knowledge and skill decay

• Used within an educational framework simulation training could reduce the theory-practice gap (Shepherd et al, (2007)

Implications for nursing Implications for nursing practice and educationpractice and education

• Exposure to simulation training can effectively prepare nurses’ to deal with at-risk patients’ and respond to medical crisis situations, possibly reducing practice error.

• Allow nurse to become acquainted with effects of new drugs within a safe supportive environment.

• Simulation can be used to practice and introduce new skills and procedures.

Recommendations for using Recommendations for using simulation as a teaching method simulation as a teaching method

• Simulation is only beneficial and effective in nursing if used appropriately by educators and combined with a relevant educational framework, which can be integrated into the curricula Shepherd et al (2007)

• Well articulated learner outcomes with clear connection to course/ clinical objectives (DeVita et al (2005); Bremner et al, (2006)

• The planning, implementing & evaluation of simulation training should be done in collaboration with the student (Bremner et al, (2006).

The role of the educatorThe role of the educator• Considered the most important factor to ensure effective

simulation-based education • Adequately prepared to provide simulation training with

clear guidelines on designing, developing, running and evaluating simulation (Alinier et al, (2006); Shepherd et al, (2007)

• The educators’ role needs to combine elements of explaining, refereeing, coaching and discussing (Schoening et al, (2006)

• Minimal interaction with the students during scenarios facilitates critical thinking and decision-making, allowing students to learn from their mistakes (Alinier et al, (2006)

Future research Future research

• Larger more robust studies, which are multi-site experimental pre-test post test design (Shapiro et al, (2004); DeVita et al, (2005).

• Video recording, structured observation provide inter-rater reliability of the results & enables consequent checking of the consistency of verbal & non-verbal behaviour (Shepherd et al, (2007)

• Observations carried out in real practice could compare how participants function in the real world (Mole and McLafferty (2003).

Future researchFuture research

• Measure knowledge outcomes, increased self-efficacy, skill mastery, and transferability to clinical practice, using reliable, valid data collection tools which compares simulation to traditional methods (Schoening et al, (2007)

• Address the unanswered questions of whether simulation training has an impact on actual care (Shapiro et al, (2004); DeVita et al, (2005).

• Explore the ideal frequency and mode of training for refresher courses

• Whether learning and retention is improved?

ConclusionsConclusions• Evidence supports the use of simulation in nursing

education to be an effective teaching strategy to assess and strengthen the skills and competences in nursing practice Simulation as a teaching method is complex, multifaceted and challenging

• Facilitators’ – appropriate training• Adequate resources to design, develop and plan

simulation training• Further research studies focus on measuring the

impact simulation training has on clinical practice and patient outcomes

Conclusions Conclusions

• Simulation in nursing education is an effective teaching strategy to assess and strengthen the skills and competences in nursing practice

• In comparison with traditional teaching methods, simulation appears to be a more effective teaching method

Questions?Questions?

For full reference list Contact details:

• sarah.@bmsc.co.uk• Visit

www.bmsc.co.uk