- Email: [email protected]
Substitution of Clinical Experience With Simulation in Prelicensure Nursing Programs: A National Survey in the United States
Clinical Simulation in Nursing (2015) 11, 472-478
www.elsevier.com/locate/ecsn
Featured Article
Substitution of Clinical Experience With Simulation in Prelicensure Nursing Programs: A National Survey in the United States Tonya L. Breymier, PhD, RN, CNEa,*, Tonya Rutherford-Hemming, EdD, RN, ANP-BC, CHSEb, Trisha Leann Horsley, PhD, RN, CHSE, CNEc, Teresa Atz, PhD, RNd, Lisa G. Smith, PhD, RN, CNEe, Donna Badowski, DNP, MSN, RN, CNEf, Kelley Connor, RN, MS, CNE, CHSEg a
Assistant Professor and Associate Dean for Nursing Graduate Programs, Indiana University East, Richmond, IN 47374 Senior Nurse Researcher, Cleveland Clinic Foundation, Cleveland, OH 44195 c Assistant Professor, Loyola University Chicago Marcella Niehoff School of Nursing, Chicago, IL 60153 d Assistant Professor, Assistant Director of Health Care Simulation, Medical University of South Carolina, Charleston, SC 29425 e Associate Professor, College of Nursing and Healthcare Professions, Grand Canyon University, Phoenix, AZ 85017 f Assistant Professor and Assistant Director, DePaul University, Chicago, IL 60604 g Assistant Professor, Boise State University School of Nursing, Boise, ID 83725 b
KEYWORDS simulation substitution; simulation ratio; supervised clinical ratio; facilitator-to-student ratio; substitution ratio
Abstract Background: Some states allow simulation substitution of supervised clinical instruction. However, a review of the literature found that a standard substitution ratio for simulation hours to supervised clinical hours does not exist among prelicensure nursing programs. Method: A descriptive survey was sent to more than 1,400 prelicensure schools of nursing. Results: Schools of nursing reported various substitution ratios demonstrating ambiguity between institutions. Conclusion: This study provided an initial view of current practices related to simulation as a substitution for supervised clinical experiences. Cite this article: Breymier, T. L., Rutherford-Hemming, T., Horsley, T. L., Atz, T., Smith, L. G., Badowski, D., & Connor, K. (2015, November). Substitution of clinical experience with simulation in prelicensure nursing programs: A national survey in the united states. Clinical Simulation in Nursing, 11(11), 472-478. http://dx.doi.org/10.1016/j.ecns.2015.09.004. Ó 2015 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
Background This paper is a product of the INACSL Research Committee. * Corresponding author: [email protected] (T. L. Breymier).
Simulation in nursing is used to meet a variety of teaching needs. Simulation mimics the supervised clinical experiences
1876-1399/$ - see front matter Ó 2015 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ecns.2015.09.004
Simulation Substitution Ratios
473
while providing students similar opportunities to demonstrate procedures, participate in clinical decision-making, utilize critical thinking, and communicate with each other in a nonthreatening, standardized environment (Jeffries, 2005). Examples of simulation activities include high-, medium-, and low-fidelity manikins, role-playing, standardized Key Points patients, or interactive, Simulation is subcomputer-based critical stituted for supervised thinking scenarios (Hayden, clinical instruction. Jeffries, Kardong-Edgren, & The ratio of simulaSpector, 2009). Additional tion to supervised learning activities related to clinical hours varies. traditional clinical experi Ambiguity exists difences can include pre- and ferentiating percentpostclinical conferences, age of simulation clinical paperwork detailing used versus ratio of patient care plans, and simulation to superskills laboratories (National vised clinical hours. Council for State Boards of Nursing [NCSBN], 2005). A growing area of simulation instruction includes substituting supervised clinical instruction with simulation experiences. The National Council for State Boards of Nursing Simulation Study determined that simulation could be substituted for traditional clinical hours with equivocal education outcomes in prelicensure nursing programs (Hayden, Smiley, Alexander, Kardong-Edgren, & Jeffries, 2014). Supervised clinical experiences are typically defined as supervised learning activities that assist the student to apply nursing knowledge and skills in the direct care of patients (NCSBN, 2005). Nurses who supervise students in these experiences are faculty members or clinical preceptors. These individuals are licensed Registered Nurse’s practicing in the clinical sites who volunteer to supervise students and give feedback to course faculty (Hayden et al., 2014). Many state boards of nursing are allowing simulated experiences to replace a defined number of supervised clinical hours (Arizona State Board of Nursing, 2015; Nehring, 2008). However, a review of the literature found that a standard substitution ratio for simulation hours to supervised clinical hours does not exist among prelicensure nursing programs. CINAHL, ProQuest and EBSCOhost were accessed using the search terms simulation, nursing, and survey. Only four articles were found within the last 10 years that addressed simulation use for supervised clinical hours (Garrett, MacPhee, & Jackson, 2011; Katz, Peifer, & Armstrong, 2010; Nehring, 2008; McGarry, Cashin, & Fowler, 2014). Two of the four articles referenced U.S. surveys. One was sent to all U.S. boards of nursing including Washington, D.C. and Puerto Rico (Nehring, 2008). The second article surveyed selected baccalaureate of science in nursing programs (Katz et al., 2010). The other two articles
reported survey results from Australia (McGarry et al., 2014) and Canada (Garrett et al., 2011). All four of these surveys included a question that addressed percentage or hours of simulation substituted for supervised clinical instruction hours. None of these surveys ascertained the ratio used to determine the number of simulation hours to supervised clinical instruction hours. A gap in the literature exists regarding what is known about the ratio of simulation hours to supervised clinical instruction hours used in prelicensure nursing programs.
Purpose of the Study The purpose of this study was to determine the ratios of simulation to supervised clinical instruction used in prelicensure curricula. In addition, this study evaluated the facilitator-to-student ratios used in simulation and supervised clinical instruction. The study also investigated the rationale for substituting simulation in place of supervised clinical instruction, the person or people that made the decision(s) about substitution, and how the substitution ratio was determined. The research questions guiding this study were the following: 1) When simulation is used in place of supervised clinical instruction in a prelicensure nursing program, what is the ratio of simulation to supervised clinical instruction hours per nursing course? 2) What are the simulation and supervised clinical instruction facilitator-to-student ratios? 3) What is the rationale for substituting simulation in place of supervised clinical instruction? 4) Who makes the decision in determining the simulation substitution ratios? 5) How is the ratio of simulation to supervised clinical instruction determined?
Methods Participants and Data Collection Procedures This study was determined to be exempt by the institutional review board at Indiana University East. Participants were recruited through convenience sampling. An e-mail, inviting individuals to participate in the study and providing an electronic link to the survey, was sent to the attention of deans, chairs, or program directors at prelicensure nursing schools. Clicking on the link implied consent to participate in the study.
Measurement Instrument A 22-item survey was developed for the purpose of this research. To assess content validity, the items on the survey were sent to 20 content experts in simulation. Five experts
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returned feedback. After reviewing the feedback, two questions were eliminated, and several questions were edited for clarity. Content validity index of the 21-item survey was 0.92. Removal of the two questions and movement of one question to the demographics section improved the content validity index to 0.95. The final survey consisted of six demographic questions followed by simulation survey questions. For the simulation survey questions, three questions were ‘‘yes or no.’’ One question asked participants to select one answer, whereas 12 questions asked participants to ‘‘check all that apply.’’ Two questions that asked about ratios were open ended.
Statistical Analysis Data were screened using exploratory data analysis methods to identify any data anomalies. Descriptive analyses were used to examine the data; categorical factors were described using frequencies and percentages. Participant responses to the open-ended questions were read, and traditional thematic analysis techniques were used to analyze the data.
Table 1
Characteristics of Schools of Nursing and Faculty
Type of school Public 268 (62.0%) Private (nonprofit) 135 (31.3%) Private (for-profit) 20 (6.7%) Nursing degrees offered Associate 199 (46.2%) Bachelor (prelicensure) 221 (51.3%) Bachelor (postlicensure) 176 (40.8%) Masters 155 (36.0%) Doctoral 94 (21.8%) Other 36 (8.4%) Types of simulation training received by faculty Workshop 212 (49.2%) Formal education 44 (10.2%) Continuing education 344 (79.8%) Vendor 262 (60.8%) On the job training 363 (84.2%) None of the above 8 (1.9%) Other 9 (2.1%) Types of simulation used Low fidelity 360 (92.5%) Moderate-/mid-level fidelity 335 (86.1%) High fidelity 347 (89.2%) Values presented as N (column %).
Results Four hundred thirty-two (32%) individuals responded to the online survey. Every state was represented. Approximately 99% of participants indicated that simulation is used as a teaching methodology in their nursing program, and 77.5% of participants indicated that their nursing program substitutes simulation in place of supervised clinical instruction. The number of students enrolled yearly in the participating schools of nursing ranged from eight to 2,500 (median 113). Three hundred eight (71%) participants indicated that their school of nursing does not have any Certified Healthcare Simulation Educators. Other participants (n ¼ 123; 29%) indicated that their schools had between one and ten Certified Healthcare Simulation Educators. Table 1 provides characteristics of participating schools of nursing and faculty.
unstandardized ratios of simulation to supervised clinical instruction hours per nursing course.
Facilitator-to-Student Ratios Figure 3 shows the facilitator-to-student ratios for each of the nine nursing courses during simulation and the facilitator-to-student ratios for each of the nine nursing courses during supervised clinical instruction. Results depict a higher faculty-to-student ratio in the supervised clinical environment than the simulation environment.
70% 60%
Standardized versus Unstandardized Ratios
50%
One hundred forty (45%) respondents indicated that their school of nursing has a standardized ratio of simulation substitution for clinical (which means each course uses the same ratio of simulation hours to supervised clinical instruction hours). Figure 1 shows the standardized ratios of simulation to supervised clinical instruction hours. One hundred seventy (55%) respondents indicated that their school of nursing does not have a standardized ratio of simulation substitution for clinical (which means each course does not use the same ratio of simulation hours to supervised clinical instruction hours). Figure 2 shows the
3:1 (simulation:clinical) 2:1 (simulation: clinical)
40%
1:1 (simulation:clinical)
30%
1:2 (simulation:clinical) 1:3 (simulation:clinical)
20%
Other 10% 0% SimulationTime to Clinical Time
Figure 1 Standardized ratios of simulation to supervised clinical instruction hours.
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Figure 2
475
Unstandardized ratios of simulation to supervised clinical instruction hours per nursing course.
Rationale for Substituting Simulation Figure 4 displays the rationale for substituting simulation in place of supervised clinical. The question allowed participants to ‘‘select all that apply.’’ Thirty-one participants chose ‘‘Other’’ and provided the following rationales: (a) desired specific or rare experiences (55%; n ¼ 17), (b) clinical makeup (39%; n ¼ 12), (c) supplement or preparation for supervised clinical experiences (16%; n ¼ 5), (d) safety concerns (3%; n ¼ 1), and (e) supervised clinical site requested the school to offer more simulation experiences (3%; n ¼ 1).
Decision Makers for Ratios of Simulation Substitution Figure 5 displays the decision-making bodies that chose the ratio of simulation to supervised clinical instruction. The
Figure 3
question allowed participants to ‘‘select all that apply.’’ Approximately 8% (n ¼ 26) of participants provided the following written explanations for ‘‘Other’’: (a) board of nursing (46.1%; n ¼ 12), (b) all faculty (26.9%; n ¼ 7), (c) other committees (i.e., leadership council and advisory committee; 7.6%; n ¼ 2), and (d) available studies (7.65; n ¼ 2).
Determining Ratios Sixty-nine percent (n ¼ 300) provided written explanations about how ratios for substitution were determined (i.e., what process did the decision-making body utilize to determine what the ratio of simulation to supervised clinical experiences would be). Forty-eight percent (n ¼ 144) explained that the substitution ratio was determined by faculty (i.e., dependent on the course, some faculty determined based on laboratory or clinical
Facilitator-to-student ratios.
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RaƟonale for SubsƟtuƟng SimulaƟon in place of Supervised Clinical InstrucƟon- Select all that apply 100.00% 90.00% 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% Lack of clinical facilitator
Lack of clinical placements
Figure 4
Value SimulaƟon as a teaching methodology
AdministraƟve direcƟve
Other
Rationale for substitution.
credit hours, some faculty based ratio on a number as long as total simulation was less than 10% or 25% of total clinical time). In addition, 11.3% (n ¼ 34) kept the ratio equal to supervised clinical experiences (i.e., 1 hour of simulation:1 hour of supervised clinical instruction) and 8.3% (n ¼ 25) stated that they adopted the same ratio the recent National Council for State Boards of Nursing study utilized, whereas 3.3% (n ¼ 10) stated that the ratio was
determined because of lack of supervised clinical experiences, 2.3% (n ¼ 7) acknowledged that there were a variety of factors to determine the ratio (i.e. depended upon the course, depended upon the course faculty, depended upon the course level, they spoke to other programs and adopted what they were doing, etc.), and 1.6% (n ¼ 5) stated that the ratio was determined because of ‘‘constraints’’ or ‘‘lack of simulation’’ capacity. Interestingly, 13.3% (n ¼ 40)
Decision Making Body for SubsƟtuƟon RaƟo of SimulaƟon to Supervised Clinical- Select all that apply 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% Director of Nursing SimulaƟon or Program Administrator equivalent
Figure 5
Curriculum commiƩee
Individual Faculty
Course Faculty
Other
Decision-making body.
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commented that they had no idea how the current ratio was determined at their institution, and 14% (n ¼ 42) commented that their board of nursing made the determination for them.
Discussion Schools of nursing were almost evenly split between using a standardized ratio and not using a standardized ratio when substituting simulation time for supervised clinical instruction time. This demonstrates ambiguity between institutions. Some schools of nursing may feel the standard 1:1 ratio substituting simulation for supervised clinical instruction time is the ‘‘safer’’ decision because no guidelines exist to suggest a different ratio be used. Schools of nursing also may feel that the two teaching methods are truly equal in productivity. The percentage of schools who use a standardized 1:2 simulation to supervised clinical instruction ratio may be acknowledging clinical learning objectives that can be met in less time in simulation compared with supervised clinical instruction, whereas schools using the 2:1 ratio for substituting simulation time for supervised clinical instruction time may be demonstrating an uncertainty related to the benefits of simulation education. Many participants indicated that their school of nursing uses unstandardized ratios based on the course content. What many might consider foundational or cornerstone courses of nursing education (e.g., fundamentals, medicalsurgical/adult health, women’s health, and pediatrics) appear to frequently have a 1:1 ratio (Figure 1). Other courses, Older Adult, Mental Health, Community, and Leadership, are diverse not only in the ratios used when substituting simulation for supervised clinical instruction, but also in whether simulation is used and whether the course is offered. It is unclear that why certain courses have a 1:1 ratio and others do not. It may be the same reasons as those previously shared for standardized ratios. This is an area rich for further inquiry. There was great variability found in facilitator-to-student ratios for both simulation and supervised clinical instruction ranging from 1:1 ratio to 1:10 ratio. The variability may attribute to a lack of evidence in the literature leaving schools of nursing to arbitrarily assign a ratio. With no evidence, there are no set standards to use as a benchmark. The facilitator-to-student ratio was greater in the supervised clinical instruction setting than that in simulation. This finding leaves more questions than answers. Is the rationale for this finding because clinical space is often limited, so student numbers are increased per facilitator to maximize their clinical hours? Is the issue a lack of trained simulation educators who know how to properly design, implement, and evaluate the simulation experience for students? Are the facilitator-to-student ratios during supervised clinical instruction preset based on old belief systems such as ‘‘this is how we have always done it’’?
It is concerning that facilitators are responsible for more students during supervised clinical instruction compared with simulation. The simulation setting is supposed to be a safe learning environment where mistakes can be made by students. Students are not corrected or stopped before a mistake is made, yet the opposite is true of supervised clinical instruction. How can the facilitator be sure students are being monitored efficiently under supervised clinical instruction when he/she is responsible for double the number of students? It could be time is wasted by the students under supervised clinical instruction waiting for the facilitator to be available. With purposely planned simulation scenarios based on course objectives and leveled to students’ needs, time in simulation can be more efficiently managed and achieved with a lower facilitatorto-student ratio. The facilitator-to-student ratio of 1:8-9 was most popular among supervised clinical instruction, whereas 1:4-5 was the top choice for simulation. It may be that facilitators in simulation are able to spend more individual time with each student because of the smaller group size. With more time per student, facilitators may be able to pick up on subtle misunderstandings or a gap in a student’s knowledge base. Not only do facilitators have more time to assess a student’s need, but they also have more time for remediation with the student. More than 38% (n ¼ 121) of participants chose ‘‘lack of supervised clinical placements,’’ and >90% (n ¼ 285) chose ‘‘value simulation as a teaching methodology’’ as a rationale to substitute supervised clinical instruction with simulation. It is unknown if the word ‘‘value’’ biased participants because ‘‘value’’ was not defined. Less than 1% (n ¼ 1) of participants chose safety as a rationale for substituting simulation for supervised clinical instruction. This was an unexpected finding. The literature touts utilizing the simulated clinical learning environment for a safe zone to learn (Cangelosi, 2008; Kuehster & Hall, 2010; Schubert, 2012), yet the results of this study did not show that safety was identified as a rationale for substituting simulation for supervised clinical instruction. The decision-making bodies that determine the ratio of simulation to supervised clinical instruction showed interesting results. Most participants noted that the nursing program director made the determination. It is difficult to decipher if the program director makes this decision in collaboration with the body of faculty. Only 35% (n ¼ 108) of participants acknowledged simulation directors (or equivalent) being involved in the decision-making process to determine the ratio of simulation to supervised clinical instruction. The authors make the assumption that faculty appear to be involved in the decision-making process, but the simulation director (who may be the simulation expert) is not as heavily involved. It may be that few schools of nursing have simulation directors, and therefore less participants chose this answer. However, this could suggest that simulation directors are not valued for the simulation
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expertise they bring to nursing education. More research is needed to investigate these concerns. Participants were asked about the process to determine the simulation to supervised clinical ratio, and 14% (n ¼ 42) of the participants commented that their state board of nursing determined the ratio. However, State Boards of Nursing currently only determine percentages not ratios; this leads the authors to question participants’ ability to differentiate between percentages of simulation utilized and ratio of simulation to supervised clinical experiences. It is possible the participants who wrote out answers identifying their board of nursing as determining the ratio, instead of a process to determine the ratio, misunderstood the question. Limitations of this study included self-selection and limited generalizability of findings. Repeating this study with a larger and more diverse sample would increase generalizability of the findings.
Conclusion This study provided an initial view of current practices related to simulation as a substitution for supervised clinical experiences. Although the study provided a foundation of where schools of nursing are currently, it also uncovered additional questions and revealed areas rich for future research. It is necessary that these questions are answered and areas of inquiry explored to further develop best practices in simulation in nursing education.
Acknowledgments There was no extramural funding or commercial support for this study.
References Arizona State Board of Nursing. (2015). Advisory opinion; Education use of simulation in approved RN/LPN programs. Retrieved from https:// www.azbn.gov/Documents/advisory_opinion/AO%20Use%20of%20Si mulation%20in%20Pre-Licensure%20Programs.pdf. Cangelosi, P. R. (2008). Accelerated nursing students and theatre students: Creating safe environment by acting the part. Nursing Education Perspectives, 29(6), 342-346. Garrett, B. M., MacPhee, M., & Jackson, C. (2011). Implementing highfidelity simulation in Canada: Reflections on 3 years of practice. Nurse Education Today, 31, 671-676. http://dx.doi.org/10.1016/j.nedt.2010.10.028. Hayden, J. K., Jeffries, P. J., Kardong-Edgren, S., & Spector, N. (2009). The national simulation study: Evaluating simulated clinical experiences in nursing education. Unpublished research protocol. Chicago, IL: National Council of State Boards of Nursing. Hayden, J. K., Smiley, R. A., Alexander, M., Kardong-Edgren, S., & Jeffries, P. R. (2014). The NCSBN national simulation study: A longitudinal, randomized, controlled study replacing clinical hours with simulation in prelicensure nursing education. Journal of Nursing Regulation, 5(2), S3-S44. Jeffries, P. R. (2005). A framework for designing, implementing, and evaluating simulations used as teaching strategies in nursing. Nursing Education Perspectives, 26(2), 96-103. Katz, G. B., Peifer, K. L., & Armstrong, G. (2010). Assessment of patient simulation use in selected baccalaureate nursing programs in the United States. Simulation in Healthcare, 5(1), 46-51. Kuehster, C. R., & Hall, C. D. (2010). Learning from mistakes while building communication and teamwork. Journal for Nurses Staff Development, 26(3), 123-127. McGarry, D. E., Cashin, A., & Fowler, C. (2014). Survey of Australian schools of nursing use of human patient (mannequin) simulation. Issues in Mental Health Nursing, 35, 815-823. NCSBN Practice, Regulation and Education Committee. (2005). Clinical instruction in prelicensure nursing programs (pp. 1-10). Nehring, W. M. (2008). U.S. boards of nursing and the use of high-fidelity patient simulators in nursing education. Journal of Professional Nursing, 24(2), 109-117. Schubert, C. R. (2012). Effect of simulation on nursing knowledge and critical thinking in failure to rescue events. The Journal of Continuing Education in Nursing, 43(10), 467-471. http://dx.doi.org.proxyeast. uits.iu.edu/10.3928/00220124-20120904-27.
pp 472-478 Clinical Simulation in Nursing Volume 11 Issue 11
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Featured Article
Substitution of Clinical Experience With Simulation in Prelicensure Nursing Programs: A National Survey in the United States Tonya L. Breymier, PhD, RN, CNEa,*, Tonya Rutherford-Hemming, EdD, RN, ANP-BC, CHSEb, Trisha Leann Horsley, PhD, RN, CHSE, CNEc, Teresa Atz, PhD, RNd, Lisa G. Smith, PhD, RN, CNEe, Donna Badowski, DNP, MSN, RN, CNEf, Kelley Connor, RN, MS, CNE, CHSEg a
Assistant Professor and Associate Dean for Nursing Graduate Programs, Indiana University East, Richmond, IN 47374 Senior Nurse Researcher, Cleveland Clinic Foundation, Cleveland, OH 44195 c Assistant Professor, Loyola University Chicago Marcella Niehoff School of Nursing, Chicago, IL 60153 d Assistant Professor, Assistant Director of Health Care Simulation, Medical University of South Carolina, Charleston, SC 29425 e Associate Professor, College of Nursing and Healthcare Professions, Grand Canyon University, Phoenix, AZ 85017 f Assistant Professor and Assistant Director, DePaul University, Chicago, IL 60604 g Assistant Professor, Boise State University School of Nursing, Boise, ID 83725 b
KEYWORDS simulation substitution; simulation ratio; supervised clinical ratio; facilitator-to-student ratio; substitution ratio
Abstract Background: Some states allow simulation substitution of supervised clinical instruction. However, a review of the literature found that a standard substitution ratio for simulation hours to supervised clinical hours does not exist among prelicensure nursing programs. Method: A descriptive survey was sent to more than 1,400 prelicensure schools of nursing. Results: Schools of nursing reported various substitution ratios demonstrating ambiguity between institutions. Conclusion: This study provided an initial view of current practices related to simulation as a substitution for supervised clinical experiences. Cite this article: Breymier, T. L., Rutherford-Hemming, T., Horsley, T. L., Atz, T., Smith, L. G., Badowski, D., & Connor, K. (2015, November). Substitution of clinical experience with simulation in prelicensure nursing programs: A national survey in the united states. Clinical Simulation in Nursing, 11(11), 472-478. http://dx.doi.org/10.1016/j.ecns.2015.09.004. Ó 2015 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
Background This paper is a product of the INACSL Research Committee. * Corresponding author: [email protected] (T. L. Breymier).
Simulation in nursing is used to meet a variety of teaching needs. Simulation mimics the supervised clinical experiences
1876-1399/$ - see front matter Ó 2015 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ecns.2015.09.004
Simulation Substitution Ratios
473
while providing students similar opportunities to demonstrate procedures, participate in clinical decision-making, utilize critical thinking, and communicate with each other in a nonthreatening, standardized environment (Jeffries, 2005). Examples of simulation activities include high-, medium-, and low-fidelity manikins, role-playing, standardized Key Points patients, or interactive, Simulation is subcomputer-based critical stituted for supervised thinking scenarios (Hayden, clinical instruction. Jeffries, Kardong-Edgren, & The ratio of simulaSpector, 2009). Additional tion to supervised learning activities related to clinical hours varies. traditional clinical experi Ambiguity exists difences can include pre- and ferentiating percentpostclinical conferences, age of simulation clinical paperwork detailing used versus ratio of patient care plans, and simulation to superskills laboratories (National vised clinical hours. Council for State Boards of Nursing [NCSBN], 2005). A growing area of simulation instruction includes substituting supervised clinical instruction with simulation experiences. The National Council for State Boards of Nursing Simulation Study determined that simulation could be substituted for traditional clinical hours with equivocal education outcomes in prelicensure nursing programs (Hayden, Smiley, Alexander, Kardong-Edgren, & Jeffries, 2014). Supervised clinical experiences are typically defined as supervised learning activities that assist the student to apply nursing knowledge and skills in the direct care of patients (NCSBN, 2005). Nurses who supervise students in these experiences are faculty members or clinical preceptors. These individuals are licensed Registered Nurse’s practicing in the clinical sites who volunteer to supervise students and give feedback to course faculty (Hayden et al., 2014). Many state boards of nursing are allowing simulated experiences to replace a defined number of supervised clinical hours (Arizona State Board of Nursing, 2015; Nehring, 2008). However, a review of the literature found that a standard substitution ratio for simulation hours to supervised clinical hours does not exist among prelicensure nursing programs. CINAHL, ProQuest and EBSCOhost were accessed using the search terms simulation, nursing, and survey. Only four articles were found within the last 10 years that addressed simulation use for supervised clinical hours (Garrett, MacPhee, & Jackson, 2011; Katz, Peifer, & Armstrong, 2010; Nehring, 2008; McGarry, Cashin, & Fowler, 2014). Two of the four articles referenced U.S. surveys. One was sent to all U.S. boards of nursing including Washington, D.C. and Puerto Rico (Nehring, 2008). The second article surveyed selected baccalaureate of science in nursing programs (Katz et al., 2010). The other two articles
reported survey results from Australia (McGarry et al., 2014) and Canada (Garrett et al., 2011). All four of these surveys included a question that addressed percentage or hours of simulation substituted for supervised clinical instruction hours. None of these surveys ascertained the ratio used to determine the number of simulation hours to supervised clinical instruction hours. A gap in the literature exists regarding what is known about the ratio of simulation hours to supervised clinical instruction hours used in prelicensure nursing programs.
Purpose of the Study The purpose of this study was to determine the ratios of simulation to supervised clinical instruction used in prelicensure curricula. In addition, this study evaluated the facilitator-to-student ratios used in simulation and supervised clinical instruction. The study also investigated the rationale for substituting simulation in place of supervised clinical instruction, the person or people that made the decision(s) about substitution, and how the substitution ratio was determined. The research questions guiding this study were the following: 1) When simulation is used in place of supervised clinical instruction in a prelicensure nursing program, what is the ratio of simulation to supervised clinical instruction hours per nursing course? 2) What are the simulation and supervised clinical instruction facilitator-to-student ratios? 3) What is the rationale for substituting simulation in place of supervised clinical instruction? 4) Who makes the decision in determining the simulation substitution ratios? 5) How is the ratio of simulation to supervised clinical instruction determined?
Methods Participants and Data Collection Procedures This study was determined to be exempt by the institutional review board at Indiana University East. Participants were recruited through convenience sampling. An e-mail, inviting individuals to participate in the study and providing an electronic link to the survey, was sent to the attention of deans, chairs, or program directors at prelicensure nursing schools. Clicking on the link implied consent to participate in the study.
Measurement Instrument A 22-item survey was developed for the purpose of this research. To assess content validity, the items on the survey were sent to 20 content experts in simulation. Five experts
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returned feedback. After reviewing the feedback, two questions were eliminated, and several questions were edited for clarity. Content validity index of the 21-item survey was 0.92. Removal of the two questions and movement of one question to the demographics section improved the content validity index to 0.95. The final survey consisted of six demographic questions followed by simulation survey questions. For the simulation survey questions, three questions were ‘‘yes or no.’’ One question asked participants to select one answer, whereas 12 questions asked participants to ‘‘check all that apply.’’ Two questions that asked about ratios were open ended.
Statistical Analysis Data were screened using exploratory data analysis methods to identify any data anomalies. Descriptive analyses were used to examine the data; categorical factors were described using frequencies and percentages. Participant responses to the open-ended questions were read, and traditional thematic analysis techniques were used to analyze the data.
Table 1
Characteristics of Schools of Nursing and Faculty
Type of school Public 268 (62.0%) Private (nonprofit) 135 (31.3%) Private (for-profit) 20 (6.7%) Nursing degrees offered Associate 199 (46.2%) Bachelor (prelicensure) 221 (51.3%) Bachelor (postlicensure) 176 (40.8%) Masters 155 (36.0%) Doctoral 94 (21.8%) Other 36 (8.4%) Types of simulation training received by faculty Workshop 212 (49.2%) Formal education 44 (10.2%) Continuing education 344 (79.8%) Vendor 262 (60.8%) On the job training 363 (84.2%) None of the above 8 (1.9%) Other 9 (2.1%) Types of simulation used Low fidelity 360 (92.5%) Moderate-/mid-level fidelity 335 (86.1%) High fidelity 347 (89.2%) Values presented as N (column %).
Results Four hundred thirty-two (32%) individuals responded to the online survey. Every state was represented. Approximately 99% of participants indicated that simulation is used as a teaching methodology in their nursing program, and 77.5% of participants indicated that their nursing program substitutes simulation in place of supervised clinical instruction. The number of students enrolled yearly in the participating schools of nursing ranged from eight to 2,500 (median 113). Three hundred eight (71%) participants indicated that their school of nursing does not have any Certified Healthcare Simulation Educators. Other participants (n ¼ 123; 29%) indicated that their schools had between one and ten Certified Healthcare Simulation Educators. Table 1 provides characteristics of participating schools of nursing and faculty.
unstandardized ratios of simulation to supervised clinical instruction hours per nursing course.
Facilitator-to-Student Ratios Figure 3 shows the facilitator-to-student ratios for each of the nine nursing courses during simulation and the facilitator-to-student ratios for each of the nine nursing courses during supervised clinical instruction. Results depict a higher faculty-to-student ratio in the supervised clinical environment than the simulation environment.
70% 60%
Standardized versus Unstandardized Ratios
50%
One hundred forty (45%) respondents indicated that their school of nursing has a standardized ratio of simulation substitution for clinical (which means each course uses the same ratio of simulation hours to supervised clinical instruction hours). Figure 1 shows the standardized ratios of simulation to supervised clinical instruction hours. One hundred seventy (55%) respondents indicated that their school of nursing does not have a standardized ratio of simulation substitution for clinical (which means each course does not use the same ratio of simulation hours to supervised clinical instruction hours). Figure 2 shows the
3:1 (simulation:clinical) 2:1 (simulation: clinical)
40%
1:1 (simulation:clinical)
30%
1:2 (simulation:clinical) 1:3 (simulation:clinical)
20%
Other 10% 0% SimulationTime to Clinical Time
Figure 1 Standardized ratios of simulation to supervised clinical instruction hours.
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Unstandardized ratios of simulation to supervised clinical instruction hours per nursing course.
Rationale for Substituting Simulation Figure 4 displays the rationale for substituting simulation in place of supervised clinical. The question allowed participants to ‘‘select all that apply.’’ Thirty-one participants chose ‘‘Other’’ and provided the following rationales: (a) desired specific or rare experiences (55%; n ¼ 17), (b) clinical makeup (39%; n ¼ 12), (c) supplement or preparation for supervised clinical experiences (16%; n ¼ 5), (d) safety concerns (3%; n ¼ 1), and (e) supervised clinical site requested the school to offer more simulation experiences (3%; n ¼ 1).
Decision Makers for Ratios of Simulation Substitution Figure 5 displays the decision-making bodies that chose the ratio of simulation to supervised clinical instruction. The
Figure 3
question allowed participants to ‘‘select all that apply.’’ Approximately 8% (n ¼ 26) of participants provided the following written explanations for ‘‘Other’’: (a) board of nursing (46.1%; n ¼ 12), (b) all faculty (26.9%; n ¼ 7), (c) other committees (i.e., leadership council and advisory committee; 7.6%; n ¼ 2), and (d) available studies (7.65; n ¼ 2).
Determining Ratios Sixty-nine percent (n ¼ 300) provided written explanations about how ratios for substitution were determined (i.e., what process did the decision-making body utilize to determine what the ratio of simulation to supervised clinical experiences would be). Forty-eight percent (n ¼ 144) explained that the substitution ratio was determined by faculty (i.e., dependent on the course, some faculty determined based on laboratory or clinical
Facilitator-to-student ratios.
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RaƟonale for SubsƟtuƟng SimulaƟon in place of Supervised Clinical InstrucƟon- Select all that apply 100.00% 90.00% 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% Lack of clinical facilitator
Lack of clinical placements
Figure 4
Value SimulaƟon as a teaching methodology
AdministraƟve direcƟve
Other
Rationale for substitution.
credit hours, some faculty based ratio on a number as long as total simulation was less than 10% or 25% of total clinical time). In addition, 11.3% (n ¼ 34) kept the ratio equal to supervised clinical experiences (i.e., 1 hour of simulation:1 hour of supervised clinical instruction) and 8.3% (n ¼ 25) stated that they adopted the same ratio the recent National Council for State Boards of Nursing study utilized, whereas 3.3% (n ¼ 10) stated that the ratio was
determined because of lack of supervised clinical experiences, 2.3% (n ¼ 7) acknowledged that there were a variety of factors to determine the ratio (i.e. depended upon the course, depended upon the course faculty, depended upon the course level, they spoke to other programs and adopted what they were doing, etc.), and 1.6% (n ¼ 5) stated that the ratio was determined because of ‘‘constraints’’ or ‘‘lack of simulation’’ capacity. Interestingly, 13.3% (n ¼ 40)
Decision Making Body for SubsƟtuƟon RaƟo of SimulaƟon to Supervised Clinical- Select all that apply 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% Director of Nursing SimulaƟon or Program Administrator equivalent
Figure 5
Curriculum commiƩee
Individual Faculty
Course Faculty
Other
Decision-making body.
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commented that they had no idea how the current ratio was determined at their institution, and 14% (n ¼ 42) commented that their board of nursing made the determination for them.
Discussion Schools of nursing were almost evenly split between using a standardized ratio and not using a standardized ratio when substituting simulation time for supervised clinical instruction time. This demonstrates ambiguity between institutions. Some schools of nursing may feel the standard 1:1 ratio substituting simulation for supervised clinical instruction time is the ‘‘safer’’ decision because no guidelines exist to suggest a different ratio be used. Schools of nursing also may feel that the two teaching methods are truly equal in productivity. The percentage of schools who use a standardized 1:2 simulation to supervised clinical instruction ratio may be acknowledging clinical learning objectives that can be met in less time in simulation compared with supervised clinical instruction, whereas schools using the 2:1 ratio for substituting simulation time for supervised clinical instruction time may be demonstrating an uncertainty related to the benefits of simulation education. Many participants indicated that their school of nursing uses unstandardized ratios based on the course content. What many might consider foundational or cornerstone courses of nursing education (e.g., fundamentals, medicalsurgical/adult health, women’s health, and pediatrics) appear to frequently have a 1:1 ratio (Figure 1). Other courses, Older Adult, Mental Health, Community, and Leadership, are diverse not only in the ratios used when substituting simulation for supervised clinical instruction, but also in whether simulation is used and whether the course is offered. It is unclear that why certain courses have a 1:1 ratio and others do not. It may be the same reasons as those previously shared for standardized ratios. This is an area rich for further inquiry. There was great variability found in facilitator-to-student ratios for both simulation and supervised clinical instruction ranging from 1:1 ratio to 1:10 ratio. The variability may attribute to a lack of evidence in the literature leaving schools of nursing to arbitrarily assign a ratio. With no evidence, there are no set standards to use as a benchmark. The facilitator-to-student ratio was greater in the supervised clinical instruction setting than that in simulation. This finding leaves more questions than answers. Is the rationale for this finding because clinical space is often limited, so student numbers are increased per facilitator to maximize their clinical hours? Is the issue a lack of trained simulation educators who know how to properly design, implement, and evaluate the simulation experience for students? Are the facilitator-to-student ratios during supervised clinical instruction preset based on old belief systems such as ‘‘this is how we have always done it’’?
It is concerning that facilitators are responsible for more students during supervised clinical instruction compared with simulation. The simulation setting is supposed to be a safe learning environment where mistakes can be made by students. Students are not corrected or stopped before a mistake is made, yet the opposite is true of supervised clinical instruction. How can the facilitator be sure students are being monitored efficiently under supervised clinical instruction when he/she is responsible for double the number of students? It could be time is wasted by the students under supervised clinical instruction waiting for the facilitator to be available. With purposely planned simulation scenarios based on course objectives and leveled to students’ needs, time in simulation can be more efficiently managed and achieved with a lower facilitatorto-student ratio. The facilitator-to-student ratio of 1:8-9 was most popular among supervised clinical instruction, whereas 1:4-5 was the top choice for simulation. It may be that facilitators in simulation are able to spend more individual time with each student because of the smaller group size. With more time per student, facilitators may be able to pick up on subtle misunderstandings or a gap in a student’s knowledge base. Not only do facilitators have more time to assess a student’s need, but they also have more time for remediation with the student. More than 38% (n ¼ 121) of participants chose ‘‘lack of supervised clinical placements,’’ and >90% (n ¼ 285) chose ‘‘value simulation as a teaching methodology’’ as a rationale to substitute supervised clinical instruction with simulation. It is unknown if the word ‘‘value’’ biased participants because ‘‘value’’ was not defined. Less than 1% (n ¼ 1) of participants chose safety as a rationale for substituting simulation for supervised clinical instruction. This was an unexpected finding. The literature touts utilizing the simulated clinical learning environment for a safe zone to learn (Cangelosi, 2008; Kuehster & Hall, 2010; Schubert, 2012), yet the results of this study did not show that safety was identified as a rationale for substituting simulation for supervised clinical instruction. The decision-making bodies that determine the ratio of simulation to supervised clinical instruction showed interesting results. Most participants noted that the nursing program director made the determination. It is difficult to decipher if the program director makes this decision in collaboration with the body of faculty. Only 35% (n ¼ 108) of participants acknowledged simulation directors (or equivalent) being involved in the decision-making process to determine the ratio of simulation to supervised clinical instruction. The authors make the assumption that faculty appear to be involved in the decision-making process, but the simulation director (who may be the simulation expert) is not as heavily involved. It may be that few schools of nursing have simulation directors, and therefore less participants chose this answer. However, this could suggest that simulation directors are not valued for the simulation
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expertise they bring to nursing education. More research is needed to investigate these concerns. Participants were asked about the process to determine the simulation to supervised clinical ratio, and 14% (n ¼ 42) of the participants commented that their state board of nursing determined the ratio. However, State Boards of Nursing currently only determine percentages not ratios; this leads the authors to question participants’ ability to differentiate between percentages of simulation utilized and ratio of simulation to supervised clinical experiences. It is possible the participants who wrote out answers identifying their board of nursing as determining the ratio, instead of a process to determine the ratio, misunderstood the question. Limitations of this study included self-selection and limited generalizability of findings. Repeating this study with a larger and more diverse sample would increase generalizability of the findings.
Conclusion This study provided an initial view of current practices related to simulation as a substitution for supervised clinical experiences. Although the study provided a foundation of where schools of nursing are currently, it also uncovered additional questions and revealed areas rich for future research. It is necessary that these questions are answered and areas of inquiry explored to further develop best practices in simulation in nursing education.
Acknowledgments There was no extramural funding or commercial support for this study.
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