A systematic review of the effectiveness of simulation-based education on satisfaction and learning outcomes in nurse practitioner programs

    A Systematic review of the effectiveness of simulation-based education on satisfaction and learning outcomes in nurse practitioner programs Jessie N. Warren RN, MN, NP-PHC, Marian Luctkar-Flude RN, MScN, PhD(c), Christina Godfrey RN, PhD, Julia Lukewich RN, PhD PII: DOI: Reference:

S0260-6917(16)30170-8 doi: 10.1016/j.nedt.2016.08.023 YNEDT 3367

To appear in:

Nurse Education Today

Received date: Revised date: Accepted date:

18 March 2016 28 June 2016 17 August 2016

Please cite this article as: Warren, Jessie N., Luctkar-Flude, Marian, Godfrey, Christina, Lukewich, Julia, A Systematic review of the effectiveness of simulation-based education on satisfaction and learning outcomes in nurse practitioner programs, Nurse Education Today (2016), doi: 10.1016/j.nedt.2016.08.023

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ACCEPTED MANUSCRIPT 1 A SYSTEMATIC REVIEW OF THE EFFECTIVENESS OF SIMULATION-BASED EDUCATION ON SATISFACTION AND LEARNING OUTCOMES IN NURSE PRACTITIONER PROGRAMS

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Jessie N. Warren, RN, MN, NP-PHC School of Nursing, Queen‘s University Kingston, Ontario, Canada, K7L 3N6 [email protected] 613-217-1070

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Marian Luctkar-Flude, RN, MScN, PhD(c) Lecturer School of Nursing, Queen’s University 92 Barrie Street, Kingston ON K7M 8R3 [email protected] 613-533-6000 ext. 77383

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Christina Godfrey, RN, PhD Assistant Professor Scientific Director/Methodologist Queen's Joanna Briggs Collaboration, Queen's University 92 Barrie Street, Kingston, ON K7L 3N6 [email protected] 613-533-6000 ext. 78760

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Julia Lukewich, RN, PhD (corresponding author) Assistant Professor School of Nursing, Memorial University of Newfoundland 300 Prince Philip Drive, St. John's, Newfoundland, A1B 3V6 [email protected] 709-777-6319

Acknowledgments The authors would like to acknowledge Amanda Ross-White, the health science librarian, for her assistance with data collection and contribution to editing the review protocol.

Word Count: 4,684

ABSTRACT

ACCEPTED MANUSCRIPT 2 Background High-fidelity simulation (HFS) is becoming an integral component in healthcare education

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programs. There is considerable evidence demonstrating the effectiveness of HFS on satisfaction

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and learning outcomes within undergraduate nursing programs; however, there are few studies that have investigated its use and effectiveness within nurse practitioner (NP) programs.

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Objective

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To synthesize the best available evidence about the effectiveness of HFS within NP education programs worldwide. The specific review question was: what is the effect of HFS on learner

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satisfaction, knowledge, attitudes, and skill performance in NP education? Methods

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Joanna Briggs Institute systematic review methodology was utilized. The following databases were searched: MEDLINE, CINAHL, EMBASE, Epistemonikos, PROSPERO, HealthSTAR,

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AMED, Cochrane, Global Health and PsycINFO. Studies were included if they were quantitative in nature and reported on any aspect HFS within a NP program. Results

Ten studies were included in the review. All studies were conducted in the United States and published between 2007 and 2014. Outcomes explored included: knowledge, attitudes, skills and satisfaction. The majority of studies compared HFS to online learning or traditional classroom lecture. Most study scenarios featured high acuity, low frequency events within acute care settings; only two studies utilized scenarios simulated within primary care. Conclusions There is limited evidence supporting the use of HFS within NP programs. In general, HFS increases students’ knowledge and confidence, and students are more satisfied with simulation-

ACCEPTED MANUSCRIPT 3 based teaching in comparison to other methods. Future studies should explore the effectiveness of simulation training within NP programs in reducing the theory to practice gap, and evaluate

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knowledge retention, transferability to real patient situations, and impact of simulation on patient

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outcomes. Keywords

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Acute Care; Advanced Practice Nurses; Education; High-fidelity; Nurse Practitioners; Patient

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Simulation; Primary Care

INTRODUCTION

ACCEPTED MANUSCRIPT 4 High-fidelity simulation (HFS) has become a growing educational modality among universities since the Institute of Medicine in the United States of America (USA) recommended

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it be used to improve patient safety in 2000 (Vincent, Sheriff, & Mellott, 2015). HFS is defined

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as a replicated clinical experience using a computer-driven, full-bodied mannequin simulator with physiologic responses to interventions (Onello & Regan, 2013). It is evident from the

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literature that HFS is becoming an increasingly important aspect of learning and practicing

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clinical skills in medical programs, residency and undergraduate nursing programs (Roberts, 2011; Vincent et al., 2015). Research has demonstrated that simulation improves knowledge,

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skill performance, critical thinking and satisfaction (Boling & Hardin-Pierce, 2016; Cook et al., 2011; Lapkin et al., 2010; Shin et al., 2015). However, studies exploring its use with nurse

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practitioner (NP) students are lacking (Elliott, DeCristofaro, & Carpenter, 2012; MompointWilliams, Brooks, Lee, Watts, & Moss, 2014; Rutherford-Hemming, 2012). Thus, it is unclear

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whether HFS is an effective method for educating NP students. BACKGROUND

With advances in science and technology, knowledge of health-related disciplines is continually expanding. NP students are required to perform health assessments, diagnose and treat medical conditions in potentially complex clinical situations (Elliott et al., 2012). The use of simulation as an educational tool is becoming increasingly prevalent in nursing education (Pittman, 2012; Yuan, Williams, Fang, & Ye, 2012). HFS utilizes a computer-based mannequin, allowing for experiential training of skills, knowledge, and decision-making, which builds confidence in a safe and controlled environment and is transferable to real patient situations (Solnick & Weiss, 2007). NP education consists of classroom and online lectures supplemented with clinical instruction with the ultimate goal of promoting application of theoretical knowledge

ACCEPTED MANUSCRIPT 5 to clinical practice (Shin, Park, & Kim, 2015). Coupling simulation technology with traditional teaching methods, such as classroom lectures and textbook readings, is an effective instructional

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strategy to simulate the “real-world” clinical setting and enhance application of theory (Byrd,

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Pampaloni, & Wilson, 2012). Interactive sessions with hands-on opportunities help students link theoretical concepts with evidence-based practice (Partin, Payne, & Slemmons, 2011).

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Clinical placements in NP programs are short and competition for placements is high.

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Students may therefore lack authentic clinical exposure to many common conditions, skills, and practice environments (Wotton, Davis, Button, & Kelton, 2010). Substantial research indicates

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HFS experiences are an appropriate and much needed venue to augment traditional nursing education methods and should be strongly considered as an option in educational preparation of

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NPs (Elliott et al., 2012; Mompoint-Williams et al., 2014; Richardson & Claman, 2014). Nurse educators in both undergraduate and graduate nursing programs continue to strive to enhance

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nursing students' clinical reasoning, transference of theory to clinical practice, skill acquisition, and critical thinking (Mompoint-Williams et al., 2014). With simulation, nurse educators have the opportunity to introduce relevant technology into a theory-focused curriculum while still preserving the human component of nursing (Richardson & Claman, 2014). Theoretical Framework

Kirkpatrick’s Levels of Evaluation Model provides a useful framework for categorizing evaluations of simulation interventions (Adamson et al., 2013). The four levels of evaluation described in the framework are: (1) reaction; (2) learning; (3) behaviour; and (4) outcomes (Kirkpatrick, 1994). At the reaction level, evaluation outcomes include affective (whether participants liked the simulation intervention) or instrumental (whether participants found the training useful), and at the learning level, evaluation outcomes involve attitudes (feeling),

ACCEPTED MANUSCRIPT 6 knowledge (knowing), or skills (doing) (Agency for Healthcare Research and Quality, 2014; Kardong-Edgren, 2010). Evaluation at the behaviour level (transfer of skills to real clinical

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settings) and outcomes level (patient care results) are not commonly measured outcomes in

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nursing education as these studies are more complex and expensive to conduct (Kardong-Edgren, 2010; Shin et al., 2015).

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The widespread adoption of simulation for clinical education may now have a significant

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impact on the development of healthcare professionals including NPs. Little research identifies whether use of simulation with NP students facilitates transfer of various learning outcomes to

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clinical practice (Rutherford-Hemming, 2012). Continued research is essential to assess the effectiveness of HFS, its implications for NP education, and its ultimate impact on patient

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outcomes. A search of the Joanna Briggs Institute (JBI) Database of Systematic Reviews, Cochrane Library of Systematic Reviews, PROSPERO and Epistemonikos found no existing

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systematic reviews on this topic.

METHODS

The objective of this systematic review was to synthesize the best available evidence about the effectiveness of HFS within NP education programs worldwide. The specific review question was: what is the effect of HFS on learner satisfaction, knowledge, attitudes, and skill performance in NP education? Inclusion and Exclusion Criteria The review considered studies that explored any aspect of HFS within NP programs of various specializations. Studies focused on certified registered nurse anesthesia students, standardized patients or low-fidelity simulation were excluded. A variety of quantitative study

ACCEPTED MANUSCRIPT 7 designs, including randomized controlled trials (RCTs), non-RCTs, quasi-experimental, pretest/post-test, prospective and retrospective cohort, case control, cross-sectional studies were

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considered for inclusion. This review considered studies that explored any learner outcome

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related to HFS (e.g., knowledge, confidence, technical skill, behavioral performance, critical thinking and satisfaction).

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Search Strategy

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The three-step search strategy was developed in consultation with an academic health sciences librarian, and aimed to find both published and unpublished literature. An initial search

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of MEDLINE and CINAHL were undertaken to identify index terms and keywords. This was followed by a second extensive search using all identified index terms and keywords in the

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following databases: Epistemonikos, CINAHL, MEDLINE, PROSPERO, EMBASE, HealthSTAR, AMED, Cochrane, Global Health and PsycINFO. Keywords included: nurse

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practitioners, simulation, computer simulation, patient, education, nursing, medical education, and nursing education. Studies were limited to the English language. There were no date limitations placed on the review. Articles deemed relevant were retrieved for full-text review and assessed for inclusion using the pre-established selection criteria. Furthermore, reference lists of all included articles and reports were searched for additional relevant studies. Assessment of Quality Quantitative papers selected for retrieval were assessed by two independent reviewers for methodological validity prior to inclusion in the review using two standardized critical appraisal instruments from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI): (1) JBI Critical Appraisal Checklist for Experimental Studies. (Randomized Control Trial/Pseudo-randomized Trial); and (2) JBI Critical Appraisal Checklist

ACCEPTED MANUSCRIPT 8 for Descriptive/Case Series Studies (Joanna Briggs Institute, 2014). Any disagreements that arose between the reviewers were resolved through discussion, and a third reviewer was not

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required. Due to the limited number of relevant studies, studies were included in this review if

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they scored a minimum of four out of ten on the experimental studies checklist or three out of nine on the descriptive studies checklist, where scores of zero to three were considered lower

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quality (higher risk of bias) and scores of seven or more were considered high quality (low risk

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of bias). Data Extraction and Synthesis

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Quantitative data were extracted from included studies using standardized data extraction tools from JBI-MAStARI. Data extracted included details about study design,

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sample/participants, HFS interventions/scenarios, measurement tools, key results/outcomes, and overall conclusions. Given the heterogeneity in outcome measures, meta-analysis was not

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possible. Therefore, study findings are presented in narrative form with tables to aid in data presentation. Kirkpatrick’s Training Evaluation Model provided the framework for analysis of the review findings (Kirkpatrick, 1994). Study results were organized according to the four levels of evaluation outlined in the model to facilitate recognition of trends within the data. RESULTS

Overview of Studies Ninety-three studies were identified through database searching and other sources (Figure 1). Ten studies met the defined inclusion criteria and were included in the final review. A detailed summary of the articles is located in Table 1. All included studies were published in the USA between 2007 and 2014. Overall, sample sizes were small, ranging from seven to ninetynine participants. Four studies were experimental with randomized two-group, pre-test/post-test

ACCEPTED MANUSCRIPT 9 designs (Becker, 2007; Corbridge, Robinson, Tiffen, & Corbridge, 2010; Johnson et al., 2014; Scherer, Bruce, & Runkawatt, 2007) , two were quasi-experimental, non-equivalent control

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group designs (Anderson, 2007; Leflore et al., 2007) and the remaining four were quasi-

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experimental one-group, pre-test/post-test designs (Bruce et al., 2009; Corbridge et al., 2008; Kaplan, Holmes, Mott, & Atallah, 2011; Haut et al., 2014). Furthermore, two of these studies

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were PhD dissertations (Anderson, 2007; Becker, 2007).

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All studies involved a single simulation education event, except the study completed by Johnson et al. (2014), which incorporated four simulation scenarios three weeks apart from each

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other. Three studies compared HFS with online learning (Anderson, 2007; Corbridge et al, 2010; Johnson et al., 2014) and three compared HFS with a traditional classroom lecture or seminar (

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Becker, 2007; LeFlore et al., 2007; Scherer et al., 2007). In the remaining four studies, students served as their own controls in the evaluation of the simulation intervention (Bruce et al., 2009;

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Corbridge et al., 2008; Kaplan et al., 2011; Haut et al., 2014). All studies simulated an acute care setting, except two that simulated a primary healthcare setting (Anderson, 2007; LeFlore et al., 2007). Studies employed either pediatric scenarios (Anderson, 2007; Haut et al., 2014; Kaplan et al., 2011; LeFlore et al., 2007) or adult scenarios (Becker, 2007; Bruce et al., 2009; Corbridge et al., 2008, 2010; Johnson et al., 2014; Scherer et al., 2007). Pediatric scenarios included sepsis, respiratory distress, asthma exacerbation and a mock “code” (Haut et al., 2014; Kaplan et al., 2011; LeFlore et al., 2007); adult scenarios included acute coronary syndrome, acute abdominal pain, respiratory distress, mechanical intubation, cardiac arrest, pneumonia, sepsis, and rapid atrial fibrillation. The study conducted by Anderson (2007) was the only study to utilize a low acuity primary healthcare scenario involving a newborn assessment (Anderson, 2007).

ACCEPTED MANUSCRIPT 10 Student-level outcomes measured within the studies included knowledge (Anderson, 2007; Bruce et al., 2009; Corbridge et al., 2008, 2010; Haut et al., 2014; Johnson et al., 2014;

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LeFlore et al., 2007; Scherer et al., 2007), attitudes (Anderson, 2007; Bruce et al., 2009;

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Corbridge et al., 2008; Kaplan et al., 2011; LeFlore et al., 2007; Scherer et al., 2007), skill performance (Bruce et al., 2009; Johnson et al., 2014; LeFlore et al., 2007; Becker, 2007), and

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learner satisfaction (Anderson, 2007; Bruce et al., 2009; Corbridge et al., 2008, 2010; Haut et al.,

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2014; Scherer et al., 2007), Methodological Quality

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Given the paucity of research in this area, all relevant studies were included. The methodological quality of most studies was moderate, with a range of scores from six to seven

experimental studies.

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out of ten for the experimental studies, and a range from three to seven out of nine for the quasi-

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The major risk of bias for the experimental studies was due to lack of blinding of participants and assessors, which is difficult to achieve with educational interventions. The major risk of bias for the quasi-experimental studies was due to non-random sampling and not addressing potential confounding factors. As well, outcomes of individuals who withdrew from the studies were generally not described, and the majority of studies did not report whether any participants had withdrawn. Findings of the Review Satisfaction Several studies demonstrated NP student satisfaction related to HFS (Corbridge et al., 2008; Corbridge et al., 2010; Haut et al., 2014; Kaplan et al., 2014). Specifically, students reported enthusiasm and enjoyment with HFS experiences (Corbridge et al., 2008; Haut et al.,

ACCEPTED MANUSCRIPT 11 2014; Kaplan et al., 2011). As well, NP students perceived HFS to enhance their critical thinking skills, evidence-based practice (Corbridge et al., 2008), and knowledge and ability to function in

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the clinical setting (Kaplan et al., 2011). Knowledge

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Student’s knowledge acquisition was measured in several studies (Anderson, 2007; Bruce

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et al., 2009; Corbridge et al., 2008, 2010; Haut et al., 2014; Johnson et al., 2014; LeFlore et al.,

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2007; Scherer et al., 2007). In general, patient simulation was determined to be a better tool for evaluation of knowledge acquisition (LeFlore et al., 2007; Scherer et al., 2007), in comparison to

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traditional education measures that typically evaluate knowledge by a standard paper-pencil test (LeFlore et al., 2007). In two pre-test/post-test studies, NPs knowledge related to critical care

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(e.g. cardiac arrest management) significantly increased after participation in HFS (Corbridge et al., 2008; Bruce et al., 2009). In a third study, post-test scores increased, but non-significantly

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(Haut et al., 2014). Furthermore, five studies compared knowledge acquisition resulting from HFS to non-simulation education (Anderson, 2007; Scherer et al., 2007; Corbridge et al., 2010; Haut et al., 2014; Johnson et al., 2014). Four of these studies demonstrated overall increases in NP students’ knowledge regardless of teaching modality utilized (Corbridge et al., 2010; Haut et al., 2014; Johnson et al., 2014; Scherer et al., 2007), whereas a single study demonstrated higher post-test knowledge scores for the HFS group (Anderson, 2007). Attitudes Attitudes that are commonly measured as outcomes of simulation include confidence and self-efficacy. With respect to NP self-reported confidence in managing various clinical scenarios, several studies found a significant increase in overall confidence following participation in a HFS (Kaplan et al., 2011, Corbridge et al., 2008, Bruce et al., 2009). For instance, NP student

ACCEPTED MANUSCRIPT 12 confidence significantly improved from “somewhat confident” to “very confident” after participation in a simulation focused on managing a mechanically ventilated patient (p=0.031)

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and a patient in circulatory shock (p=0.007) (Corbridge et al., 2008). Similarly, participation in

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simulation scenarios resulted in a significant increase in NP student’s confidence in identifying whether a rhythm was shockable or non-shockable (p=0.041), determining indications for

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defibrillator use (p=0.026), and administering vasopressin (p=0.005) (Bruce et al., 2009). NP

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students in the study by Haut and colleagues (2014) strongly agreed that the simulation experience: better prepared them to care for real patients; increased their confidence in their

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decision-making skills; and increased their ability to recognized patient status changes. Results related to effects of HFS on NP student self-efficacy were reported in only two

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studies. Anderson and colleagues (2007) found no significant difference between NP student perceived self-efficacy when HFS was integrated with lecture content in comparison to

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traditional lecture format (Anderson, 2007). In contrast, LeFlore and colleagues (2007) conducted a pilot study comparing traditional education to two applications of HFS, namely instructor modelled learning (IML) and self-directed learning (SDL). Despite NPs within the traditional education group being older and having more nursing experience, these NPs scored significantly lower on the Self-Efficacy Tool (SET) at three times points (i.e. time 1: p=0.006; time 2: p=0.008; time 3: p=0.012) in comparison to NP students in the IML and SDL groups (LeFlore et al., 2007). Skills The terms skill, competence, behaviour and performance are often used synonymously in the simulation literature to refer to the observed abilities demonstrated by learners. Skills or behavioural performance commonly measured during simulation include technical or clinical

ACCEPTED MANUSCRIPT 13 skills, such as inserting a Foley catheter or performing a chest assessment, nontechnical skills, such as communication and teamwork, and cognitive skills, such as critical thinking. Studies in

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this review reported a variety of outcome measures related to skill performance.

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Technical skill performance was measured by LeFlore and colleagues (2007) using a technical evaluation tool (TET) (LeFlore et al., 2007). The TET scored student performance on

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history taking, physical assessment and ordering interventions (scores range between 0-32). A

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significant difference was noted between the groups (i.e. traditional education, HFS using IML, HFS using SDL) specially with respect to the time it took to start albuterol (p=0.025), however

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this difference was only by about two seconds (LeFlore et al., 2007). Two studies measured clinical behaviours of NP students during simulation education

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events using behavioral assessment tools (Haut et al., 2014; LeFlore et al., 2007), both utilizing a

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quasi-experimental designs. Haut et al. (2014) explored acute care NP students’ behaviours

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during simulation using the Simulation Module for Assessment of Resident Targeted Event Responses (SMARTER) behavioral assessment tool. This tool is comprised of 22 targeted clinical responses. Three groups completed a simulation scenario related to pediatric sepsis and at least 60% of the targeted clinical responses were completed by the NP students (Haut et al., 2014). The decision to perform lumbar puncture in a child under 36 months with sepsis was only performed in one of the three groups (Haut et al., 2014). A similar study explored pediatric NP student behaviours using the Behavioural Assessment Tool during a simulation on respiratory distress in a six week old infant presenting to a primary care setting (LeFlore et al., 2007). Specifically, comparisons were made between students that participated in a SDL group and students that participated in an IML group. Statistically significant differences between the groups were demonstrated on 8 out of 10 components of the Behavioral Assessment Tool,

ACCEPTED MANUSCRIPT 14 including assumption of the leadership role, utilization of resources, communication and overall team behaviors (LeFlore et al., 2007).

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Two studies measured clinical competence in relation to HFS (Bruce et al., 2009;

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Johnson et al., 2014); however, only one had significant findings. Johnson et al. (2014) employed an experienced evaluator who used an objective performance checklist that included

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history taking and clinical management to rate NP student competence (Johnson et al., 2014).

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Significant improvements in observed competency after participation in HFS scenarios were observed by Johnson et al (2014). Specifically, the HFS group scores were significantly higher

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than the comparator group that participated in web-based education (p=0.02). Becker et al. (2007) was the only study that specifically measured critical thinking. This

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study examined the effect of HFS on critical thinking between advanced practice nursing students who participated in a simulation–centered case study session and those who participated

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in face-to-face case study analysis alone using the California Critical Thinking Skills Test (Facione, 1989) and found that critical thinking was significantly greater in the HFS group (p<0.01) (Becker, 2007).

DISCUSSION

Simulation-based learning is an educational intervention which creates an environment conducive to experiential learning (Cook et al., 2012; Solnick & Weiss, 2007). Kirkpatrick’s Levels of Evaluation provided a useful framework for categorizing the simulation intervention outcomes described in the studies included in our systematic review. Although literature on simulation in undergraduate nursing education provides evidence that simulation contributes to knowledge, attitudes and skills outcomes (Norman, 2012), evaluations at the behaviour and patient outcomes levels are not commonly measured in nursing education as these levels must be

ACCEPTED MANUSCRIPT 15 evaluated in real clinical settings (Kardong-Edgren, 2010; Shin et al., 2015). Thus it was not surprising that outcomes in the studies included in this review were measured at the reaction and

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learning levels only.

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Outcomes at the reaction or satisfaction level can be affective (whether participants liked the simulation intervention) or instrumental (whether participants found the training useful)

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(Agency for Healthcare Research and Quality, 2014; Kardong-Edgren, 2010). Findings from our

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review illustrate that NP students are generally more satisfied with HFS over traditional teaching methods and feel that it contributed to their learning. Only one study included in this review

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demonstrated lower satisfaction with HFS integrated within a lecture compared to a traditional

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the manikin (Anderson, 2007).

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lecture; however, students in the HFS group ran out of time and did not have hands-on time with

Outcomes at the learning level can involve knowledge (knowing), attitudes (feeling), or

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skills (doing) (Agency for Healthcare Research and Quality, 2014; Kardong-Edgren, 2010). In terms of knowledge, all of the studies in our review that measured pre and post-simulation knowledge scores demonstrated that knowledge was increased following HFS; however, those that compared HFS with other educational interventions did not detect significant between-group differences, except for one in which HFS group scores were higher (Anderson, 2007). As well, despite showing no significant difference in knowledge scores between HFS and online learning groups, students in the HFS group perceived a better understanding of the material and their ability to connect evidence-based practice to a patient requiring mechanical ventilation (Corbridge et al., 2010). These results suggest that HFS is generally no better than other educational interventions such as lecture or web simulation for improving knowledge in NP students; however, lack of reported validity and reliability for the knowledge tests used, as well

ACCEPTED MANUSCRIPT 16 as small sample sizes of the included studies may have contributed to an inability to detect significant differences.

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In terms of attitudes, the majority of studies in our review that measured attitudes

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demonstrated an increase in confidence post-simulation, with only one study reporting lower confidence in an HFS group over a case study seminar group (Scherer et al., 2007). Researchers

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wondered if this was due to that fact that students in the seminar group did not have to

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demonstrate hands-on skills in front of the group and discussed management of the case study as a group, compared to students in the HFS group who had to problem-solve independently,

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potentially causing them to rate their confidence lower (Scherer et al., 2007). Generally, HFSbased education increased confidence in NP students (Bruce et al., 2009; Corbridge et al., 2008;

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Kaplan et al., 2011) compared to traditional teaching methods (LeFlore et al., 2007). The results related to effects of HFS on NP student self-efficacy was limited, with one study demonstrating

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increased self-efficacy from HFS versus lecture (Leflore et al., 2007), and a second study showing increases in both groups (Anderson, 2007). Thus, overall, HFS appears to have positive effects on NP student confidence and self-efficacy. Research exploring effectiveness of HFS on skill outcomes such as critical thinking and competence in NP students remains sparse and inconclusive. Only one study measured critical thinking but clearly outlined that NP students addressed salient components of the clinical situation and displayed greater number of critical thinking behaviors and discussion in simulated scenarios compared to face-to-face sessions (Becker, 2007). Further, students in these learning situations excelled at integrating and applying essential components of the clinical cases in a focused problem-solving manner.

ACCEPTED MANUSCRIPT 17 Three studies in our review demonstrated that NP students rated higher on competence or clinical skill performance following HFS when compared to web simulation, IML or SDL

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simulation, or classroom case study (Becker, 2007; Johnson et al., 2014; Leflore et al., 2007).

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Researchers comparing IML and SDL highlighted an interesting finding in their study; students who received only traditional lecture, reflecting the traditional form of education in most NP

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programs, consistently underscored students in either of the HFS groups on almost all outcomes

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(LeFlore et al., 2007). These differences may be a reflection of the inadequacy of the traditional classroom lecture model, especially in the scenario of a six-week old in respiratory distress in the

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primary care setting used in this study (LeFlore et al., 2007). There is a growing body of evidence supporting the effectiveness of HFS on learning

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outcomes in nursing and medical education. Findings of our review are consistent with a systematic review of simulation-based learning for nursing education which demonstrated a

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positive effect of HFS on learner satisfaction, knowledge, attitudes such as confidence, and skills including critical thinking (Cant & Cooper, 2010). Similarly, a systematic review and metaanalysis of technology-enhanced simulation for the education of health professionals demonstrated consistently large effects on outcomes of knowledge, skills and behaviours in comparison with no intervention, and additionally demonstrated moderate effects for patientrelated outcomes (Cook et al., 2011). Our review obtained similar results demonstrating the effectiveness of HFS on satisfaction (reaction level) and knowledge, attitudes and skills (learning level) outcomes as described in Kirkpatrick’s model. It is important to note that, studies included in our review generally demonstrated positive outcomes resulting from a single HFS exposure ranging between ten minutes and two and a half hours. The optimal dose, frequency and duration of HFS exposure that promotes the greatest

ACCEPTED MANUSCRIPT 18 benefit in NP students’ education has yet to be determined. Despite lack of clear guidelines to recommend the most efficacious HFS design, studies in this review provided insight into future

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designs that may be necessary to optimize HFS opportunities. One study demonstrating

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knowledge improvement as shown by significant improvements in immediate post-test scores also outlined a subsequent deterioration of post-test scores at four to eight weeks after the

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intervention (Bruce et al., 2009). This study highlights an educational limitation of the HFS

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experience and researchers suggest that repetitive encounters with HFS over a more prolonged period of time may be required to improve knowledge retention; however, this requires further

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exploration (Bruce et al., 2009). Similar results were shown in another study demonstrating a loss of knowledge at one month after the intervention (Scherer et al., 2007).

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Although HFS training in nursing education has been associated with improved outcomes in comparison with other instructional modalities, the costs of both interventions were rarely

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reported, creating a challenge to make a true comparison of the value of simulation training (Cook et al., 2012). Future research should carefully document actual costs, including equipment, space, time, and salaries for development and maintenance of HFS education in NP programs in order to compare cost-effectiveness of different educational approaches. As well, future research in HFS with NP students should include higher level evaluations, evaluation of long-term retention of knowledge, transferability of this knowledge to real patient situations, and ultimately its impact on patient outcomes (Haut et al., 2014; Scherer et al., 2007). Limitations of the Review As this systematic review included only ten primary research studies it is not possible to draw adequate conclusions based on the limited quantity and quality of available evidence. Also, several studies employed small sample sizes, limiting generalizability of results. Despite utilizing

ACCEPTED MANUSCRIPT 19 a comprehensive search strategy, it is possible that not all relevant studies were retrieved and included in this review. Finally, all studies reviewed were conducted in the USA and therefore,

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findings may not be generalizable to other countries.

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CONCLUSIONS

Today NPs are faced with healthcare environments that are complex and require highly-

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developed problem-solving and decision-making skills, as well as a theoretical foundation from

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which knowledge is derived. Our review findings are consistent with previous studies conducted with undergraduate nursing and other health professional students, and they also add to the

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growing body of knowledge about HFS outcomes for NP students. Specifically, our review provides preliminary evidence of the effectiveness of HFS on NP student satisfaction (reaction

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level outcomes) and knowledge, attitudes and skills (learning level outcomes). HFS-based education may be a key component in adequately preparing NP students for a successful

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transition to clinical practice. The available literature on HFS and NP education suggests that simulation is useful in creating a learning environment that contributes to learner satisfaction, knowledge, confidence, competence and critical thinking. Findings thus far indicate that simulated experiences are an appropriate option to augment traditional nursing education methods and should be considered in the educational preparation of competent NPs. This systematic review provides a foundation for further research to be completed to provide a sound basis for supporting use of HFS in NP education. Conflicts of Interest There are no conflicts of interest.

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References Adamson, K.A., Kardong-Edgren, S., & Willhaus, J. (2013). An updated review of published simulation evaluation instruments. Clinical Simulation in Nursing, 9(9), e393-e400. http://dx.doi.org/10.1016.j.ecns.2012.09.004

ACCEPTED MANUSCRIPT 21 Agency for Healthcare Research and Quality. (2014). TeamSTEPPS 2.0 Module 10: Measurement. Agency for Healthcare Research and Quality, Rockville, MD. Retrieved from: http://www.ahrq.gov/professionals/education/curriculumtools/teamstepps/instructor/fundamentals/module10/igmeasure.html

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Anderson, M. (2007). Effect of integrated high-fidelity simulation in knowledge, perceived selfefficacy and satisfaction of nurse practitioner students in newborn assessment. Unpublished doctoral dissertation, Texas Women’s University, Denton, TX.

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Becker, D. E. (2007). The effect of patient simulation on the critical thinking of advanced practice nursing students. Unpublished doctoral dissertation, Drexel University, Philadelphia, PA Benner, P. (1982). From Novice to Expert. American Journal of Nursing, 82(3), 402–407.

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Boling, B., & Hardin-Pierce, M. (2016). The effect of high-fidelity simulation on knowledge and confidence in critical care training: An integrative review. Nurse Education in Practice, 16, 287-293. http://dx.doi.org/10.1016/j.nepr.2015.10.004

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Bruce, S. A., Scherer, Y. K., Curran, C. C., Urschel, D. M., Erdley, S., & Ball, L. S. (2009). A collaborative exercise between graduate and undergraduate nursing students using a computer-assisted simulator in a mock cardiac arrest. Nursing Education Perspectives, 30(1), 22–7.

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Byrd, J., Pampaloni, F., & Wilson, L. (2012). Hybrid simulation. In L. Wilson (Ed). Human Simulation for Nursing and Health Professions, (pp.267-271). New York: Springer Publishing.

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Cant, R., & Cooper, S. (2010). Simulation-based learning in nurse education: Systematic review. Journal of Advanced Nursing, 66(1), 3-15. Cook, D. A., Brydges, R., Hamstra, S. J., Zendejas, B., Szostek, J. H., Wang, A. T., … Hatala, R. (2012). Comparative effectiveness of technology-enhanced simulation versus other instructional methods: a systematic review and meta-analysis. Simulation in Healthcare : Journal of the Society for Simulation in Healthcare, 7(5), 308–20. http://doi.org/10.1097/SIH.0b013e3182614f95 Cook, D.A., Hatala, R., Brydges, R., Zendejas, B., Szostek, J.H., Wang, A.T., Erwin, P.J., & Hamstra, S.J. (2011). Technology-enhanced simulation for health professions education: A systematic review and meta-analysis. Journal of the American Medical Association, 306(9), 978-988. Corbridge, S. J., McLaughlin, R., Tiffen, J., Wade, L., Templin, R., & Corbridge, T. C. (2008). Using simulation to enhance knowledge and confidence. The Nurse Practitioner, 33(6), 12–13. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/18528196 Corbridge, S. J., Robinson, F. P., Tiffen, J., & Corbridge, T. C. (2010). Online learning versus simulation for teaching principles of mechanical ventilation to nurse practitioner students. International Journal of Nursing Education Scholarship, 7, Article12. http://doi.org/10.2202/1548-923X.1976 Elliott, L., DeCristofaro, C., & Carpenter, A. (2012). Blending technology in teaching advanced health assessment in a family nurse practitioner program: using personal digital assistants

ACCEPTED MANUSCRIPT 22 in a simulation laboratory. Journal of the American Academy of Nurse Practitioners, 24(9), 536–43. http://doi.org/10.1111/j.1745-7599.2012.00728.x

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Facione, P. A. (1989). The California Critical Thinking Skills Test--College Level. Technical Report #2. Factors Predictive of CT Skills. Retrieved from http://eric.ed.gov/?id=ED327550

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Haut, C., Fey, M. K., Akintade, B., & Klepper, M. (2014). Using High-fidelity Simulation to Teach Acute Care Pediatric Nurse Practitioner Students. The Journal for Nurse Practitioners, 10(10), e87–e91. http://doi.org/10.1016/j.nurpra.2014.09.012

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Joanna Briggs Institute (2014). Joanna Briggs Institute Reviewers’ Manual: 2014 Edition. Adelaide, Australia: The Joanna Briggs Institute. Retrieved from http://joannabriggs.org/assets/docs/sumari/reviewersmanual-2014.pdf

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Johnson, M. P., Hickey, K. T., Scopa-Goldman, J., Andrews, T., Boerem, P., Covec, M., & Larson, E. (2014). Manikin Versus Web-Based Simulation for Advanced Practice Nursing Students. Clinical Simulation in Nursing, 10(6), e317–e323. http://doi.org/10.1016/j.ecns.2014.02.004

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Kaplan, B. G., Holmes, L., Mott, M., & Atallah, H. (2011). Design and implementation of an interdisciplinary pediatric mock code for undergraduate and graduate nursing students. Computers, Informatics, Nursing : CIN, 29(9), 531–8. http://doi.org/10.1097/NCN.0b013e31821a166e

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Kardong-Edgren, S. (2010). Striving for higher levels of evaluation in simulation. Clinical Simulation in Nursing, 6, e203-e204. doi: 10.1016/j.ecns.2010.07.001

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Kirkpatrick, D. (1994). Evaluating training programs: The four levels. San Francisco: BerrettKoehler. Lapkin, S., Levett-Jones, T., Bellchambers, H., & Fernandez, R. (2010). Effectiveness of patient simulation manikins in teaching clinical reasoning skills to undergraduate nursing students: A systematic review. Clinical Simulation in Nursing, 6, e207-e222. doi:10.1016/j.ecns.2010.05.005 LeFlore, J. L., Anderson, M., Michael, J. L., Engle, W. D., & Anderson, J. (2007). Comparison of self-directed learning versus instructor-modeled learning during a simulated clinical experience. Simulation in Healthcare: Journal of the Society for Simulation in Healthcare, 2(3), 170–7. http://doi.org/10.1097/SIH.0b013e31812dfb46 Mompoint-Williams, D., Brooks, A., Lee, L., Watts, P., & Moss, J. (2014). Using High-fidelity Simulation to Prepare Advanced Practice Nursing Students. Clinical Simulation in Nursing, 10(1), e5–e10. http://doi.org/10.1016/j.ecns.2013.07.005 Norman, J. (2012). Systematic review of the literature on simulation in nursing education. The ABNF Journal : Official Journal of the Association of Black Nursing Faculty in Higher Education, Inc, 23(2), 24–8. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/22774355 Onello, R., & Regan, M. (2013). No Title Challenges in high fidelity simulation: Risk sensitization and outcome measurement. Online Journal of Issues in Nursing, 18(3), 34– 41.

ACCEPTED MANUSCRIPT 23 Partin, J. L., Payne, T. A., & Slemmons, M. F. (2011). Students’ perceptions of their learning experiences using high-fidelity simulation to teach concepts relative to obstetrics. Nursing Education Perspectives, 32(3), 186–8. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/21834381

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Pittman, O. A. (2012). The use of simulation with advanced practice nursing students. Journal of the American Academy of Nurse Practitioners, 24(9), 516–20. http://doi.org/10.1111/j.1745-7599.2012.00760.x

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Richardson, K. J., & Claman, F. (2014). High-fidelity simulation in nursing education: a change in clinical practice. Nursing Education Perspectives, 35(2), 125–7. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/24783730

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Roberts, D. (2011). The theatre of high-fidelity simulation education. Nurse Education Today, 31(7), 694 – 698. Retrieved from http://resolver.scholarsportal.info/resolve/02606917/v31i0007/694_ttohse.xml

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Rutherford-Hemming, T. (2012). Learning in simulated environments: effect on learning transfer and clinical skill acquisition in nurse practitioner students. The Journal of Nursing Education, 51(7), 403–6. http://doi.org/10.3928/01484834-20120427-04

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Scherer, Y. K., Bruce, S. A., & Runkawatt, V. (2007). A comparison of clinical simulation and case study presentation on nurse practitioner students’ knowledge and confidence in managing a cardiac event. International Journal of Nursing Education Scholarship, 4(1), Article22. http://doi.org/10.2202/1548-923X.1502

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Shin, S., Park, J.-H., & Kim, J.-H. (2015). Effectiveness of patient simulation in nursing education: Meta-analysis. Nurse Education Today, 35(1), 176–182. http://doi.org/10.1016/j.nedt.2014.09.009 Solnick, A., & Weiss, S. (2007). High Fidelity Simulation in Nursing Education: A Review of the Literature. Clinical Simulation in Nursing, 3(1), e41–e45. http://doi.org/10.1016/j.ecns.2009.05.039 Vincent, M. A., Sheriff, S., & Mellott, S. (2015). The efficacy of high-fidelity simulation on psychomotor clinical performance improvement of undergraduate nursing students. Computers, Informatics, Nursing : CIN, 33(2), 78–84. http://doi.org/10.1097/CIN.0000000000000136 Wotton, K., Davis, J., Button, D., & Kelton, M. (2010). Third-year undergraduate nursing students’ perceptions of high-fidelity simulation. Journal of Nursing Education, 49(11), 632–9. http://doi.org/10.3928/01484834-20100831-01 Yuan, H. Bin, Williams, B. A., Fang, J. B., & Ye, Q. H. (2012). A systematic review of selected evidence on improving knowledge and skills through high-fidelity simulation. Nurse Education Today, 32(3), 294–8. http://doi.org/10.1016/j.nedt.2011.07.010

ACCEPTED MANUSCRIPT 24

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Additional records identified through other sources (n=1)

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Records identified through database searching (n=92)

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Identification

Figure 1: PRISMA Flow Diagram

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Screening

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Records after duplicates removed (n=66 )

Records excluded (n=40 )

Included

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Full-text articles assessed for eligibility (n=26 )

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Eligibility

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Records screened (n=66 )

Full-text articles excluded (n=16)

Reasons for exclusion: - Nurse Anesthetists (n=3) - Not NP students (n=2) Studies included in quantitative synthesis (n=10)

- Not HFS (n=2) - Weak evidence/not primary studies (n=9)

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2nd year Acute Care Pediatric Nurse Practitio ner (ACPNP ) students

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Group size: 3-4

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Results

Knowledge: multiple choice question (MCQ) quiz

Study Quali ty

Knowledg Moder e: mean ate score (6/9)* improved from 61% Performance: pre-test to 78% postSimulation test Pediatric Module for (p=0.09) sepsis Assessment with a of Resident Performan HFS child Targeted ce: manikin Event students and Responses accomplis standardi (SMARTER) hed the zed behavioral majority patient assessment of the (SP) tool; required portrayin measures responses; g the knowledge, group 1 parent skills & (73%), attitudes group 2 related to (68%), core group 3 competences (60%); for pediatric critical acute care; decision to 22 targeted perform responses; lumbar inter-rater puncture reliability in the 78% infant with meningitis Confidence only and satisfaction: occurred in 1/3 postgroups debriefing

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To compare ACPNP students’ knowledge before and after participati on in HFS as compared with traditional learning (lecture)

Outcome Measures

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N=10 students:

Simulati on Intervent ion One 20 minute scenario with 40 minute structured debrief

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Quasiexperime ntal: one2014 group, Maryland pre-test, , USA. post-test, pilot study

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Haut et al.

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evaluation of the experience

Confidenc e: strongly agreed

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Johnson et al. 2014 New York, USA

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Study

Experime ntal: randomiz ed, twogroup, pre-test, post-test

N=32 students:

To compare ACNP and n=27 CRNA Acute students’ Care level of Nurse Practitio knowledge , attitude, ner (ACNP) and skills students related to managing n=5 acutely ill Certified patients Register between ed Nurse those Anesthet participati ist ng in HFS

Results

Study Quali ty

that experience increased their confidenc e in decisionmaking skills and ability to recognize patient status changes

Satisfactio n: strongly agreed that experience better prepared them to care for real patients Four 10Knowledge, Knowledg 15 minute Attitude and e: manikin scenarios Skill related group with 20- to managing scores 25 minute critically ill improved debrief, 3 patients: from 54% weeks selfpre-test to apart, vs. assessment 79% post60 minute questionnaire test (p < webPerformance: 0.001), based Web clinical training competencie group improved (1) acute s coronary performance from 59% to 76% (p syndrome checklist; < 0.02) ; (2) acute completed

Moder ate (6/10) **

ACCEPTED MANUSCRIPT 27 Study Purpose

(CRNA)

manikin vs. Web simulation

Outcome Measures

Results

by experienced evaluator; includes history taking (1521 items) and clinical management (12-20) items; intraclass correlation was 0.85

Attitudes: no significant changes

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Group size: 2-5

Simulati on Intervent ion abdomina l pain; (3) acute respirator y distress; and (4) sepsis

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Skill: manikin group ratings improved from 47% to 75% after training (p=0.001). Performan ce: manikin group scores improved from 52% pre-test to 70% posttest (p <0.001), Web group improved from 51% to 63% (p <0.001); manikin group had significant ly higher posttraining scores (70% vs. 63%, respectivel

Study Quali ty

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Results

Study Quali ty

To describe the n=43 Bachelor developme nt and of Science evaluation of a pilot in Nursing program using HFS (BSN) to teach n=12 critical Emergen thinking, cy Nurse resuscitati Practitio on skills ner for a (ENP) critically ill infant, Group and team size: communic 5 BSN ation. and 2 NP students

One 20 minute scenario with 40 minute structured debrief

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N=55 students:

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Kaplan et Quasial. experime ntal: 2011 oneGeorgia, group, USA pre-test, post-test

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y; p=0.02)

Pediatric mock code simulatio n with ENP students acting as team leader

Confidence: self-report survey Satisfaction: postsimulation evaluation survey

Confidenc e: increased from 80.65% to 100% in the ENP group Satisfactio n: ENP group agreed/str ongly agreed that the simulation was: well organized (50%/50% ), enjoyable (33%/66% ), prompted realistic reactions (53%/30% ), increased knowledg e base (50%/50%

Low (3/9)

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Outcome Measures

2010 Illinois, USA.

Experime ntal: randomiz ed, twogroup, pre-test, post-test

N=20 students:

To determine differences Adult, geriatric in knowledge and acquisition acute and care Advance student satisfactio d Practice n between two Nurse methods of (APN) teaching students: principles Nurse Practitio of ner (NP) mechanica l and Clinical ventilation to APN Nurse Specialis students t (CNS)

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One scenario vs. online, narrated PowerPoi nt presentati on

Knowledge: investigator designed 12 item MCQ test; content validity established with review by NP and physician experts in mechanical ventilation Satisfaction: postsimulation evaluation survey; 5item, 5-point Likert scale; Cronbach’s

Results

Study Quali ty

), concepts clarified in debriefing (26%/60% ), scenarios believable (33%/66% ) and increased ability to function in clinical setting (58%/42% ); high level of teamwork appreciate d Knowledg e: HFS group improved from 4.9 (+/- 1.4) pre-test to 9.2 (+/1.3) posttest (p<0.001); online training group improved from 4.1 (+/-0.8) to 9.1 (+/1.7) (p<0.001); between group

Moder ate (6/10)

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alpha 0.92

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students

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scores did not differ significant ly at posttest (p=0.891) Satisfactio n: HFS group score of 24.6 (+/0.97) was higher than online group score of 19.3 (+/2.9) (p<0.0001 ); HFS group unanimou sly agreed they would recommen d the teaching style to other students, while online group generally disagreed; HFS group perceived better understan

Study Quali ty

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Outcome Measures

n=9 Adult NP (ANP) n=107 BSN

Group size: 1 NP and 4-5 BSN students

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One 90 minute cardiac arrest scenario including debrief. NP students immediat ely repeated the scenario.

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n=2 ACNP

To evaluate undergrad uate BSN and ACNP/AN P students’ knowledge , confidence , and clinical competenc e in managing a crisis cardiac arrest situation

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New York, USA

N=118 students:

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2009

Quasiexperime ntal: onegroup, pre-test, post-test

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Bruce et al.

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Study

NP students were educated about crisis managem ent and cardiac arrest managem ent and were oriented to the sim centre pre-sim.

Knowledge: 10-item MCQ test based on AHA guidelines Confidence: Confidence Scale (16 items on 5 point Likert scale) Competence: Student Competency scale (26 items)

Results

Study Quali ty

ding of material and their ability to transfer it patient care Knowledg Moder e: all item ate scores (6/9) improved at post-test (t= -11.35; p=0.0001) , except “Pulse checks should generally be performed …”

Confidenc e: scores improved Satisfaction: significant Evaluation ly for item instrument 2 (identify (12 items in whether 5 point rhythm is Likert scale, shockable) 4 open ended (p=0.041), Qs) item 5 (identify indication s for defibrillat or use) (p=0.026), and item 8

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Outcome Measures

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Study

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(vasopress in) (p=0.005) Competen ce: only a few NP students were able to carry out entire algorithm; total scores improved from Time 1 to Time 2 (not significant ly) Satisfactio n: overall mean of 4.2 (range 1 to 5); weaknesse s—too much informatio n provided ahead of time; strengths — opportunit y to take charge in crisis and employ problem solving skills.

Study Quali ty

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Quasiexperime ntal: onegroup, pre-test, post-test

N=7 ACNP students

To determine the effect of simulation on knowledge acquisition and confidence , and to study ACNP perception of the importance of simulator training

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Illinois, USA

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2008

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Corbridg e et al.

Simulati Outcome on Measures Intervent ion One 2.5 Knowledge: hour 13-question scenario validated written test Patient with pneumoni a and septic shock in the intensive care unit (ICU)

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Confidence: 2 question, 5point Likert scale survey

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Satisfaction: 5-question, 5 point Likert scale survey

Results

Knowledg e: mean scores improved from 7.1 (+/-2.4) pre-test to 10.3 (+/1.5) posttest (p=0.019) Confidenc e: in managing a mechanica lly ventilated patient improved from “somewha t not confident” to “very confident” (p=0.031); confidenc e managing circulatory shock improved from “somewha t not confident” to “very confident” (p=0.007) Satisfactio

Study Quali ty Low (3/9)

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Study

Leflore et Quasial. experime ntal: non2007 equivalen Texas, t control USA group, pilot study

N=16 pediatric nurse practitio ner (PNP) students enrolled in their first pediatric manage ment course:

n=5 instructo r modeled learning

To compare instructor modeled learning with selfdirected learning during a clinical simulated experience

Control group: lecture plus one selfdirected simulatio n SDL: lecture, simulatio n, facilitated debrief, plus repeated simulatio n IML:

Knowledge: 10-item Knowledge Assessment Test (KAT); scored 0100; instructordeveloped based on PALS guidelines and lecture content

Results

Study Quali ty

n: students “agreed” or “strongly agreed” that simulation enhanced critical thinking skills and evidencebased practice, and that the experience was fun, realistic, and should be mandatory Knowledg e: no significant difference s between groups at time 1 (p=0.58), time 2 (p=0.44), or time 3 (p=0.51)

SelfEfficacy: Selfsignificant Efficacy: difference Michael’s s between adaptation of groups on Self-Efficacy the SET at

Moder ate (5/9)

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(IML) group

Outcome Measures

Tool (SET); reliability 0.93; scored 15-60

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n=5 control group

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Group size: 5-6

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6-week old with respirator y distress.

Results

time 1 (p=0.006), time 2 (p=0.008) and time 3 KAT and (p= SET: prelecture (pre- 0.012); test/ time1) , control group post-lecture scored (postsignificant test1/time2) and post-sim ly lower in self(post-test efficacy 2/time3) than SDL Technical and IML Performance: groups at Technical all three Evaluation time Tool (TET), points developed Technical based on Performan learning objectives in ce: only 1of 9 SOAP componen (subjective, ts of TET objective, statisticall assessment, plan) format; y significant scored 0-32 between Behavioural groups Performance: (time to Behavioural start Assessment albuterol, Tool (BAT) p=0.025); adapted from however, Crisis slightly Resource over 2 Management seconds (CRM); may not Cronbach’s be alpha 0.83considered

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n=6 selfdirected learning (SDL) group

Simulati on Intervent ion lecture, observati on of instructor modeled simulatio n, modified debriefin g, plus simulatio n

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0.92

Scherer et al. 2007 New York, USA

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TET and BAT scored by 2 evaluators (NP and MD) blinded to training type

Experime ntal: randomiz ed, twogroup, pre-test, post-test

N=23 students: n=8 adult nurse practitio ner (ANP) n=15 ACNP Groups: n= 13 experim ental simulati on group

To compare the efficacy of controlled simulated mannequin -assisted learning and case study presentatio n on knowledge and confidence of NP students in managing a cardiac

One 1520 minute simulatio n of adult in rapid A-fib, then a group debriefin g session. Control group: one-hour clinical seminar on same case

Knowledge: case study format Knowledge Quiz with four categories of open-ended questions (assessment, differential diagnosis, management, and medications) , scored out of 15

Both groups

Confidence: 10 item, 4

Results

Study Quali ty

clinically significant Behaviour al Performan ce: statisticall y significant difference s between the groups in 8 out of 10 BAT componen ts, plus the overall team behaviors

Knowledg e: no significant difference s between pre and post-test scores for either group Confidenc e: simulation group scored lower (25.64 +/6.7) than seminar

High (7/10)

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Particip ants

event

Simulati on Intervent ion received 60minute PowerPoi nt instructio n on managem ent of atrial arrhythmi as

Outcome Measures

Results

point Likert Confidence scale, based on Bandura’s Self-efficacy Theory

group (31.30 +/3.6) at post-test 1 (p=0.04)

Satisfaction: 6 item, 4 point Likert scale Evaluation Instrument

Satisfactio n: no statisticall y significant difference s between groups.

Becker. 2007 Pennsylv ania, USA

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n=10 control seminar group

Study Purpose

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Experime ntal: randomiz ed, twogroup, pre-test, post-test

N=128 APN students:

To examine the effect human n=20 patient nurse anestheti simulation had on the st (NA) critical n=99 NP thinking of student advanced practice Group size: 2-6 nursing students n=67 participati control ng in group simulation

Pre-tests: post-lecture

Study Quali ty

Post-test 1: one week post simulation/se minar Post-test 2: one month post simulation/se minar

Online pretest, 11.5 hours One of two 1hour case studies Control group: face-toface case study analysis in a classroom

Critical Thinking: 34-item MCQ California Critical Thinking Skills Test (CCTST), validity .74 Behaviours: critical thinking discourse and behaviours

Critical Thinking: simulation generated more critical thinking than the face-toface method (p<0.01) Behaviour s: simulation group

Moder ate (6/10)

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-centered case study analysis sessions, as compared to those participati ng in faceto-face case study analysis sessions alone

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n=61 experim ental groups

Simulati Outcome on Measures Intervent ion setting observed by Experime trained coder using the ntal Critical group: simulatio Thinking Coding Form n(CTCF) centered

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case study analysis

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Case A: cardiovas cular problem

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Case B: pulmonar y problem

Results

demonstra ted increased critical thinking discourse and behaviors (p<0.05); mean scores were significant ly higher in simulation sessions during the problem exploratio n stage (p<0.01); deep critical thinking mean scores during the integration phase were significant ly higher in simulation sessions than in the face-toface sessions case study analysis

Study Quali ty

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AC CE P n=48 experim ental group n=23 control group

20 minutes of simulatio n integrated within a 2-hour lecture

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To compare knowledge , perceived selfefficacy, and satisfactio n between NP students enrolled in Advanced Health Assessmen t who received traditional didactic lecture compared with those who received lecture integrated with a HFS for newborn assessment

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N=72 NP students in various specialti es in an advance d health assessme nt course:

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Anderson Quasi. experime ntal, non2007 equivalen Texas, t control USA. group

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Study

Experime ntal group: lecture integrated with highfidelity simulatio n Control group: traditiona l didactic lecture

Knowledge: 10-item MCQ Newborn Assessment Knowledge Tool, validated test, scored 0-100

Results

Study Quali ty

sessions (p<0.01); little variation existed between subjects related to the type of case study completed

Knowledg e: statisticall y significant difference s observed between the knowledg e pre-test Selfand postefficacy: test 1 Perceived Self-Efficacy (p<0.001) and Tool for between Newborn Assessment, the knowledg Cronbach’s e pre-test alpha .93 and postSatisfaction: test 2 Educational (p<0.001); Session not Satisfaction between Tool, 5-point post-test 1 Likert scale and posttest 2; Pre-tests: significant pre-lecture betweenPost-test 1: group post-lecture difference

High (7/9)

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Outcome Measures

Results

Post-test 2: 4 weeks postlecture

s observed on knowledg e pre-test (p=.04) and posttest 1 (p< .001)

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SelfEfficacy: statisticall y significant difference s observed within each group between pre-test and posttest 1 scores (p<0.001) and between pre-test and posttest 2 scores (p<0.001); but not between post-test 1 and posttest 2 scores (p=0.9); no significant between group

Study Quali ty

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difference s observed on pretest, posttest 1 or post-test 2 Satisfactio n: no statisticall y significant difference s noted between the groups (p=0.27).

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Note: *Descriptive studies were scored out of 9; **Experimental studies were scored out of 10 using JBI assessment tools.

ACCEPTED MANUSCRIPT 42 Table 2: Summary of High Fidelity Simulation (HFS) Outcomes

Satisfact ion

+ effect on preparati on for clinical practice

Kaplan One et al. HFS 2011 group

+ effect on knowled ge & performa nce HFS > online group

Knowle dge

SelfConfide nce/ SelfEfficacy

Behaviour Critica s/ l Competen Thinki ce/ ng Performan ce

↑ at post-test not better than lecture

+ effect on confiden ce in decisionmaking

D

Haut et One al. high 2014 fidelity simulat ion (HFS) group Johnso HFS vs n et al. web 2014 simulat ion

Skills

AC CE P

TE

↑ for both groups

Corbri dge et al. 2010

HFS vs online

Bruce et al. 2009

One HFS group

+ opportun ity to take

↑ for both groups, no differen ce between groups ↑ at post-test

RI

Group s

Attitude s

SC

Study

Knowle dge

NU

Outcome Measured

Level 2: Learning

PT

Level 1: Reaction

MA

Kirkpatrick Level of Evaluation

no significa nt changes

Most requiremen ts achieved; 1/3 made critical decision ↑ selfreport skill ratings ↑ for both groups HFS > web group

↑ confiden ce post sim

↑ confiden ce on 3/16

↑ (nonsignifi cant) few able to

Level 3: Behavi our

Level 4: Outco mes

Transf er of Skills to Clinica l Setting

Patient Care Results

ACCEPTED MANUSCRIPT 43

One HFS group

no differen ce between groups

AC CE P

Leflore Lecture et al. vs self2007 directe d (SDL) vs instruct ormodele d (IML) Schere HFS vs no r et al. seminar differenc 2007 es between groups

Classro om vs HFS case study Anders HFS vs on lecture 2007

PT

Skills Critica Behaviour l carrys/out Thinki entire Competen ng ce/ algorithm Performan ce

RI

↑ at post-test

Attitude s SelfConfide items nce/ post sim SelfEfficacy ↑ confiden ce at post-test

SC

Corbri dge et al. 2008

charge in crisis & problemsolve + effect on critical thinking skills & evidence -based practice

Knowle dge Knowle dge

NU

Satisfact ion

MA

Outcome Measured

Level 2: Learning

SDL & IML group selfefficacy >lecture group

IML >lecture for 9/10 items SDL > lecture for 3/10 items

D

Level 1: Reaction

TE

Kirkpatrick Level of Evaluation

no differen ces between groups

HFS group confiden ce < seminar group at post-test

Becker . 2007

HFS > classro om

no differenc es between groups

↑ for both groups, HFS > lecture

↑ selfefficacy for both groups, no

HFS > classroom

Level 3: Behavi our

Level 4: Outco mes

Transf er of Skills to Clinica l Setting

Patient Care Results

ACCEPTED MANUSCRIPT 44

Satisfact ion

Knowle dge Knowle dge

Attitude s SelfConfide differenc e nce/ Selfbetween Efficacy groups

Skills Critica l Thinki ng

NU MA D TE AC CE P

PT

Outcome Measured

Level 2: Learning

Behaviour s/ Competen ce/ Performan ce

RI

Level 1: Reaction

SC

Kirkpatrick Level of Evaluation

Level 3: Behavi our

Level 4: Outco mes

Transf er of Skills to Clinica l Setting

Patient Care Results

ACCEPTED MANUSCRIPT 45 Research Highlights

TE

D

MA

NU

SC

RI

PT

Few studies have investigated high fidelity simulation in nurse practitioner programs. Ten studies identified exploring high fidelity simulation with nurse practitioners. Most studies have explored a single simulation event within an acute care setting. High fidelity simulation has increased knowledge, confidence, and satisfaction. High fidelity simulation may be key aspect in preparing nurse practitioner students.

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