- Email: [email protected]
Integrating Simulation Innovatively: Evidence in Teaching in Nursing Education
Clinical Simulation in Nursing (2012) 8, e169-e175
www.elsevier.com/locate/ecsn
Featured Article
Integrating Simulation Innovatively: Evidence in Teaching in Nursing Education Linde J.B. Wolfgram, RN, MSN*, Annette O’Leary Quinn, RN, MSN, APNP Waukesha County Technical College, Pewaukee, WI 53072, USA KEYWORDS associate degree nursing program; curriculum integration; evidence-based; nursing education; simulation learning; outcomes
Abstract: Clinical simulation has been shown to enhance nursing education. This article is a case summary of one associate degree college’s experience with simulation and describes learning outcomes in eight nursing courses after the inclusion of simulation in the curriculum. It also describes other applications of simulation prompted by faculty and student needs. Our experience showed higher skill scores and greater reported student comfort and confidence in clinical settings after participation in simulation. Simulation, when used as a learning strategy in theory courses, has generally resulted in increases in theory examination scores of 2.5% or greater. A Capstone project in the college’s simulation center in the final nursing semester is described. Medical Education Technologies Incorporated (METIÒ) and GaumardÒ simulators and evidence-based simulated clinical experiences were used in our simulation center. Cite this article: Wolfgram, L. J.B., & Quinn, A. O. (2012, May/June). Integrating simulation innovatively: Evidence in teaching in nursing education. Clinical Simulation in Nursing, 8(5), e169-e175. doi:10.1016/ j.ecns.2010.09.002. Ó 2012 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
Review of the Literature This article is a case report of one college’s experience with simulation and it presents how simulation is embedded into each of the four semesters of our program. The Office of College Advancement at Waukesha County Technical College has reviewed and approved this case report. A perusal of the literature shows that nursing education has been using simulation for more than a century, with high-fidelity simulators being used in the past decade. The computerized technology of the manikin, along with a realistic setup of the environment, creates interactive patient situations to promote skill and knowledge building. Simulation provides active learning and helps students manage anxiety and increase selfassurance and skill level. It provides a positive learning * Corresponding author: [email protected] (L. J.B. Wolfgram).
experience for novices. Simulation has been used as a teaching adjunct and as a substitute for clinical hours (Fowler-Durham & Alden, 2007). It promotes spontaneous and active thinking: thinking ‘‘on the fly’’ in changing situations. Numerous articles and studies in the nursing literature support the use and herald the benefits of high-fidelity computerized manikins in undergraduate nursing education (Bearnson & Wiker, 2005; Bremner, Aduddell, Bennett, & VanGeest, 2006; Broussard, Myers, & Lemoine, 2009; Brown, 2008; Jeffries, 2005; Wilford & Doyle, 2006). Simulators allow students to improve their level of confidence, decision-making skills, and ability to think critically (Nehring, Ellis, & Lashley, 2001). This type of learning also allows students to make errors in a sheltered, safe environment (Fowler-Durham & Alden, 2007; O’Donnell, Fletcher, Dixon, & Palmer, 1998). Knowledge and communication skills are improved with simulation use, as are interdisciplinary teamwork and
1876-1399/$ - see front matter Ó 2012 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
doi:10.1016/j.ecns.2010.09.002
Integrating Simulation Innovatively
e170
interpersonal and psychomotor skills (Lasater, 2007). Simulation can aid the nursing student in applying theoretical concepts to clinical presentations and contexts and narrow this integration gap. Because of increasing patient acuity in inpatient settings, students must come to the clinical site better able to deal with rapidly changing situations Key Points and greater technological The ADN program at interventions. Improved Waukesha County decision-making abilities Technical College and greater awareness of pahas embedded simutient safety have been demlation learning using onstrated with the use of evidence-based data simulation and quality deinto the nursing briefing (Henneman, curriculum. Cunningham, Roche, & The use of simulation Cumin, 2007). is described at each A systematic review of level of the student’s this method of learning in education. nursing education supports Other simulation apthe belief that simulation is plications, unique exan effective and valid learnperiences unavailable ing and teaching strategy to students in clinical (Cant & Cooper, 2009). Stusettings and a descripdents have the opportunity tion of the final semesto participate in high-acuity, ter Capstone project low-frequency situations in are provided. a simulated environment. They have the ability, as students, to be directly involved with skills and tasks that may be denied to them or simply not presented in a clinical setting (e.g., telephoning a health care provider for orders, administering blood products, and dealing with cardiac arrest situations). Students have the chance to repeatedly practice working with fast-paced, emergent, and highstress situations in a realistic, yet simulated, environment. Simulation strives to reproduce essential aspects of clinical situations in order that these circumstances can be more easily managed and better understood in the real setting (Hovancsek, 2007). Wilford and Doyle (2006) have combined Miller’s pyramid model of competence in skill learning with simulation learning to illustrate improvement in ability, proficiency, and confidence. Simulation has been used as a remediation tool with nursing students to allow for multiple opportunities in order to ensure proficiency in routine assessment or skills (Haskvitz & Koop, 2004). Undergraduate nursing curricula across the world have embraced and widely incorporated this teaching and learning tool (McKenna, French, Newton, & Cross, 2007; Murray, Grant, Howarth, & Leigh, 2008; Nehring, 2008). One study (Brannan, White, & Bezanson, 2008) has shown simulation is a superior teaching tool to effect knowledge, critical thinking, and confidence, particularly in comparison with classroom lecture techniques. This literature review supports the effectiveness of simulation in a teachingelearning environment.
Program History and Description Waukesha County Technical College (WCTC) officially opened the Human Patient Simulator (HPS) Center on May 1, 2007. Prior to the opening of the lab, other simulation centers in the area were toured. Conversations were held with faculty and staff at these centers to explore reasons for success and to discuss potential and actual problems. This expertise was used in the design and organization of our simulation center. Funding from a U.S. Department of Labor grant allowed the purchase of two Medical Education Technologies (METIÒ) simulators, a high-fidelity adult and a pediatric emergency care simulator. There is a dedicated full-time simulation technician for the lab and assigned faculty equivalent to one full-time position. Funding for those positions initially came from the Department of Labor grant but now has been incorporated into the nursing department’s budget. WCTC faculty’s and administration’s experience has been that these positions are critical to the high usage and success of our program, and they have therefore been made part of the operating budget. A Gaumard birthing simulator was added, and the Emergency Medical Services department has a Laerdal adult simulator in the HPS Center. Our nursing department also purchased METI’s Program for Nursing Curriculum Integration (PNCI) product. The PNCI consists of more than 90 written and preprogrammed evidence-based simulated clinical experiences (SCEs) for use with the infant, pediatric, or adult simulators. Each SCE includes a learner and faculty guide. Integration of simulation into our nursing curriculum began immediately with clinical make-up and open lab sessions. In the fall of 2007, clinical and skills courses dedicated student time in the HPS Center, emphasizing difficult course content or high-acuity clinical situations. All WCTC clinical and theory faculty use simulation methodology. Typical faculty usage is 4 hours every semester. This is a combination of clinical hours and theory hours. The nursing department has seen a great increase in student usage since the opening, as shown in Figure 1. Between the fall of 2007 and the spring of 2009, WCTC’s nursing program averaged 200 students in total. In the fall of 2007, 273 students participated in 819 hours of simulation. Students participate in multiple simulation experiences throughout the semester. In the spring of 2009, 793 students (same students attend multiple simulation sessions) participated in 2,250 hours of simulation. In addition, our simulation center ran 55 scenarios in the fall of 2007, and that increased to 116 scenarios in the spring of 2009. Scenarios are repeated as faculty and students require. The nursing program at WCTC is divided into four semesters for the full-time associate degree in nursing (ADN) student.
First Semester In the first semester of our four-semester nursing program, full-time nursing students must complete three theory
pp e169-e175 Clinical Simulation in Nursing Volume 8 Issue 5
Integrating Simulation Innovatively
e171 WCTC - HPS Center Utilization
2500
2232
2250
2205
2000
Student Hours
1500
Students
1000
Simulated Scenarios
819
744
735
793
500 273 55
115
100
116
0 Fall 2007 Figure 1
Spring 2008
Fall 2008
Spring 2009
Waukesha County Technical College Human Patient Simulator Center use.
courses and one 90-hour clinical course. One of these theory courses is a nursing skills class, in which physical assessment techniques are taught. This course concludes before the clinical course begins, and a student must demonstrate a competent head-to-toe physical assessment in this skills course before advancing to the clinical course. This demonstration is a graded performance in the skills class curriculum. To accompany didactic content, an optional 2-hour physical assessment open lab simulation experience is offered to students. In this lab, physical assessment skills are practiced by students in the presence of an instructor. It is not a mandatory part of class because of curriculum time constraints. The student-to-faculty ratio is 8:1, and three simulators are available for students. The physical assessment open lab was heavily promoted by faculty and enjoyed a good reputation among students and over two semesters, fall 2008 and spring 2009; 93% (89 of 96) of the students in the skills class attended the open lab. The seven students who did not attend all reported a schedule conflict that prevented their attendance. The physical assessment simulation labs were facilitated by one faculty member, who was also an instructor in the skills class and would be one of five faculty grading the physical assessment in the skills theory course. To determine whether the additional experience of attending a physical assessment simulation lab would affect the physical assessment graded skills performance scores, we gathered data from the rubric used by the faculty of the skills course (see Online Extra Appendix 1 at www.nursingsimulation.org). A scale of 1 through 5 was used in the rubric, with 3.95 being a passing score of 79%. The 79% is a predetermined pass rate for the Department of Nursing at WCTC. As shown in the
grading rubric, a score of 5 meets all criteria. The average score for the 89 students who attended the simulation was 4.91 out of 5, which we compared with the average score (4.79 out of 5) of 94 students who did not have the physical assessment simulation lab option in the fall of 2007 and the spring of 2008. In addition to comparing scores of these two groups of students, we asked a question of clinical faculty. The question was, ‘‘Did you observe an improvement in performance in the students’ head-to-toe assessment in clinical practice? Please comment.’’ The faculty reported observing more accuracy and confidence being demonstrated in clinical practice by the students who had attended the physical assessment simulation lab. Additionally, during the first semester, one 5-hour day of an 18-day clinical medicalesurgical rotation (approximately 5.5% of total clinical time) is spent practicing simulation with a medicalesurgical scenario. Nursing instructors work with their own clinical students in simulation and can adjust the scenario to resemble the specific hospital setting where the students will be practicing. Student feedback about this experience is obtained through a course evaluation question: ‘‘Were your clinical experiences positively affected by the day spent in simulation?’’ This question was answered via a 5point Likert-type scale, and 80 out of 96 students (83%) responded with a score of 5 (exceeded expectations) or 4 (met expectations). The other points along the Likert-type scale included 3 (expectations partially met), 2 (expectations rarely met), and 1 (expectations not met) All narrative comments by students were highly positive toward the experience. Many students stated that they felt they could move ‘‘up to speed’’ more quickly in clinical because unit-specific policies and instructor expectations were clearly defined during an initial simulation experience.
pp e169-e175 Clinical Simulation in Nursing Volume 8 Issue 5
Integrating Simulation Innovatively
e172
Health Promotions Course Evaluations 20 Students
12 6
1
Figure 2
0
1
Health promotions course evaluations, 20 students.
Second Semester During the second semester of our nursing program, didactic content on obstetrical, neonatal, and mental health nursing is a part of our health promotion course. An obstetrical clinical course and a mental health clinical course occur concurrently with this didactic course. Faculty in the health promotion course felt that simulation would enhance learning beyond classroom discussion. A decision was made to include two required simulation experiences. These instructors were able to incorporate these simulation experiences into classroom time or clinical time. For the labor and delivery content, clinical preparation is held in our simulation center, making use of the program’s birthing manikin, and is facilitated by women’s health faculty. This is a 2-hour experience that occurs 1 day before the obstetrical clinical rotation begins. Content that includes nursing assessment and care in the neonate and newly delivered mother is built into a basic simulation scenario using the newborn and birthing manikins. A group of four students cares for simulated patients who have had a vaginal or cesarean delivery. Students are required to provide a postpartum assessment and basic newborn teaching for the simulation mothers. Because student perception is positively associated with confidence levels, perception of value was evaluated at the end of the semester. During the health promotion course evaluation, the question was asked, ‘‘Did the labor, delivery, newborn simulation meet your expectations in learning this content?’’ Using a 5point Likert-type scale, 18 out of 20 students (90%) in the spring 2009 semester rated this experience with a 5 (exceeded expectations) or 4 (met expectations). The other points on the Likert-type scale included 3 (expectations partially met), 2 (expectations rarely met), and 1 (expectations not met). See Figure 2. Narrative comments were all positive; for example, ‘‘I felt more prepared to care for my patients on the postpartum unit.’’ To augment our neonatal curriculum, a respiratory distress syndrome and septic baby syndrome are offered for students. These are offered as optional simulation labs and are not offered during normal class time. Of the total class, 8 out of 20 students (40%) took advantage of this opportunity in the spring 2009 semester. For the students who
participated in these simulations, theory test scores on four questions targeting respiratory distress or neonatal sepsis averaged 87.5% correct, compared with 85% from those who did not attend the simulations. The difference in test score averages is not statistically significant. When students were informally asked why they chose not to participate in optional labs, they cited time and schedule constraints. It could also be theorized that students who have time to attend optional simulations also have more time to study, and that could contribute to higher test scores. As the use of simulation evolves in our nursing program, certain simulations will have a mandatory attendance requirement. However, it is anticipated that optional simulation attendance will continue to meet some learners’ needs. In 2007, our program recognized the need for mental health scenarios and developed an alcohol withdrawal SCE. Our second-semester students spend 1 clinical day (5 hours) participating in this SCE as part of their mental health clinical course. Anecdotal student feedback has been consistently positive regarding this experience, and reported student comfort level at clinical sites caring for this patient population has improved.
Third Semester The third semester of our program includes two clinical rotations, an acute care setting and a community-based setting (urgent cares, day surgeries, school settings, and gastrointestinal or cancer centers). The theory components include a complex health alterations course, an advanced nursing skills course, and a mental health course. At the third level of our program, students work through either a pediatric fluid and electrolyte or a diabetic ketoacidosis SCE. This SCE strengthens fluid and electrolyte knowledge and provides students with much needed pediatric opportunities. For the spring 2009 semester, 38 out of 45 students (84%) agreed or strongly agreed that the HPS lab provided scenarios that gave a better understanding of pathophysiology and medications. In fall 2008, 33 out of 38 students (87%) positively rated increased confidence from HPS experiences in decision-making and assessment skills. This information was gathered from student selfreported anonymous surveys completed at the end of the semester. The course evaluations consist of 12 questions, 2 of which are directly related to simulation experience in the course (see Online Extra Appendix 2 at www. nursingsimulation.org). Comments from both semesters included ‘‘have more HPS sessions’’ and ‘‘have an additional day in HPS.’’ In our third-level advanced skills course, each student was required to attend a blood administration and transfusion reaction scenario to practice, through simulation, the process of blood verification and prompt recognition of and response to an adverse reaction. Test content statistics are tracked for every written examination. Correct answers on theory test
pp e169-e175 Clinical Simulation in Nursing Volume 8 Issue 5
Integrating Simulation Innovatively
e173
content related to blood administration increased from an average of 86% prior to student simulation use to an average of 90.3% when students attended simulation. Student feedback from this simulation has been extremely positive.
Fourth Semester In the final semester of our ADN program, students have 229 clinical hours during 14 weeks in an acute care setting. Concurrently, students have another complex health alterations course and a management and professional concepts theory course. At the fourth level of our program, clinical competency is assessed in a final, capstone project. In the 4 weeks before graduation, a student nurse is expected to care for a patient having a typical medicalesurgical inpatient experience. To help the students prepare for this graded project, a capstone preparation day is required. With minimal faculty guidance, four students are assigned simulation roles (primary nurse, medication nurse, resource nurse, and documentation nurse) and then care for a simulated patient for 2 hours. Students have commented that this preparation day has decreased anxiety and increased learning and confidence. Students also participate in an hour-long session the week of capstone to again become familiar and comfortable with the simulated environment, the location of supplies, the medication cart, and the manikin itself. Students have remarked that being able to tour the space just prior to this graded experience has greatly lowered anxiety. For the graded capstone simulation, the student is given report on a patient and a set of orders to be completed. An SCE from METI’s PNCI scenario list, modified by the clinical instructor, is selected. Modifications have included the addition of skills, addition of parenteral medications, and minor changes to provider orders or assessment findings. These scenarios are dedicated solely to the capstone project, and students have never encountered these specific scenarios during their previous simulation experiences. In real time, the student is expected to competently and efficiently complete care for this patient. A detailed rubric is used by faculty to evaluate students (see Online Extra Appendix 3 at www. nursingsimulation.org). This rubric was developed by one of the college’s nursing faculty, Beth Connell-Weiand, MSN, APN, MSHA. The rubric links critical course competencies and minimal expected observable behaviors. METIÒ’s listed minimal expected behaviors from the PNCI scenario are used. The rubric contains 100 points, and each student is evaluated on skill performance, leadership ability, communication, critical thinking, and safety. Faculty evaluators, who are also the clinical faculty for students, have commented that simulation performance for marginal students mirrored performance in clinical. A score of 79% or higher on the rubric is considered successful. HPS capstone projects have been in place for four semesters, 118 students have participated, and
5 (4%) have been unsuccessful. Reasons for failure include the student’s inability to recognize his or her own unsafe behavior; inability to prioritize, manage care, and think critically; or inability to perform nursing skills competently. In spring 2009, HPS sessions were incorporated into the second Complex Health Alterations course in order to reinforce content identified as difficult by students and faculty. These areas included pregnancy-induced hypertension; shock (septic and neurological); and hepatic, gastrointestinal, and renal concepts. Students were required to attend one scenario focusing on one of these content areas, facilitated by course faculty. Test scores on all assessed content areas except pregnancy-induced hypertension and renal improved with implementation of this requirement, increasing by between 2.6% and 7.4%. All examination scores were tracked and evaluated. It is postulated that both content areas are very challenging. However, students reported the HPS experiences for this course as ‘‘a great help’’ and ‘‘also helpful.’’ At the conclusion of our program, students are required to attend a graduate feedback conversation. This is led by a facilitator from our college’s Center for Quality and Innovation, without the presence of nursing faculty. This conversation lasts from 1 to 2 hours, and students are asked a variety of questions about their educational experience, including the most valuable aspect of their education, nonvaluable educational events, and memorable faculty experiences. Students provide written comments and also verbal comments, which are transcribed by the facilitator. Information is provided to the faculty after the completion of the semester and the submission of course grades. Student comments about the HPS Center at the completion of their academic experience included, ‘‘HPS Lab was a great learning experience,’’ ‘‘I enjoyed all the HPS experiences,’’ ‘‘HPS continues to be helpful,’’ ‘‘I would like more HPS experiences,’’ and ‘‘HPS was a great tool for learning.’’ More than 90% of the student comments were positive about the HPS lab and simulated experiences.
Other Simulation Applications At WCTC, our simulation also provides the following skill experiences, in which students would not be allowed to participate in clinical practice. For example, because of state licensing laws, nursing students are not allowed to independently call health care providers for verbal orders. Also, nursing students are not allowed to open automated drug dispensing units for narcotic or house stores of medications. Both of these situations are embedded in simulations so that students can become comfortable with these experiences before graduation. Across the curriculum, clinical makeup sessions are available to students. Faculty recognizes this as a rigorous and realistic substitution for missed clinical time. These makeup sessions are offered every 4 weeks throughout the
pp e169-e175 Clinical Simulation in Nursing Volume 8 Issue 5
Integrating Simulation Innovatively
e174
semester in order to meet student needs on a timely basis. Students are permitted to miss 2 clinical days per clinical course each semester. Simulation sessions are used to meet the lost hours. In our program, if a student misses more time, hours are made up at the clinical settings or the student withdraws from the course and reenters at a later date. The state of Wisconsin has regulated the number of clinical hours per semester and per program but at this time has not formulated a policy for clinical hours coming from simulation. We have been fortunate that in our geographic location, severe clinical site shortages have not occurred. Open labs are also offered to complement theory content and to meet student requests. For example, fourth-level students have requested a labor and delivery review before their pre-National Council Licensure Examination (NCLEX) test. Mock code simulations are offered once per semester and are very popular. Open labs are not mandatory, and students receive a certificate of attendance to augment their nursing portfolios. Attendance is determined solely by the interest and the initiative of the student. When students were surveyed regarding helpful support services, the HPS lab ranked second out of 12 collegewide services. The nursing developmental skills lab and skills review sessions were listed by students as the No. 1 support service. In addition, students in the upper levels of the program who have been unsuccessful in a clinical course may be required to perform a simulation skills mastery scenario in order to reenter clinical. Adequate practice time is allowed, and students work with a faculty member in the simulation lab and complete nursing cares and an order set for a patient. The student is permitted two attempts and is evaluated by a faculty member for the HPS skills mastery sessions.
Conclusion Clinical simulation has enhanced our students’ nursing education experience and has been embraced by our faculty. The success of the program has been due in part to administrative support in funding faculty hours in simulation, as well as in funding a full-time simulation technician manager. Our state board pass rates vary between 90% and 95%, with a student retention rate in the 70th percentile. Prior to the introduction of simulation, our retention rates were in the 40th percentile. Our NCLEX pass rates have been consistently first or second in our state. WCTC is one of 5 technical schools in the 16-school Wisconsin Technical system to have introduced simulation into the nursing curriculum. As faculty, we believe that part of our success rate with retention and consistently strong NCLEX scores can be attributed to simulation learning and our students’ positive quantitative and anecdotal response to this teaching strategy. Our future simulation plans include increased simulation use in theory didactic courses, by means of tetherless, portable simulators brought into the classroom. In response to student requests, review
simulations outside the calendar year (i.e., during summer and winter breaks) will be added. Review simulations include scenarios featuring high level and demanding nursing skills and scenarios focusing on prioritization and critical thinking. The introduction and integration of simulation learning has been well received by both faculty and students in our ADN program.
References Bearnson, C., & Wiker, K. (2005). Human patient simulators: A new face in baccalaureate nursing education at Brigham Young University. Journal of Nursing Education, 44(9), 421-425, http://www. journalofnursingeducation.com. Brannan, J., White, A., & Bezanson, J. (2008). Simulator effects on cognitive skills and confidence levels. Journal of Nursing Education, 47(11), 495-500, doi:10.3928/01484834-20081101-01. Bremner, M., Aduddell, K., Bennett, D., & VanGeest, J. (2006). The use of human patient simulators: Best practices with novice nursing students. Nurse Educator, 31(4), 170-174, doi:10.1097/00006223-20060700000011. Broussard, L., Myers, R., & Lemoine, J. (2009). Preparing pediatric nurses: The role of simulation-based learning. Issues in Comprehensive Pediatric Nursing, 32, 4-15, doi:10.1080/01460860802610178. Brown, J. F. (2008). Applications of simulation technology in psychiatric mental health nursing education. Journal of Psychiatric and Mental Health Nursing, 15, 638-644, doi:10.1111/j.1365-2850.2008.001281.x. Cant, R. P., & Cooper, S. J. (2009). Simulation-based learning in nurse education: Systematic review. Journal of Advanced Nursing, 66(1), 3-15, doi:10.1111/j.1365-2648.2009.05240.x. Fowler-Durham, C., & Alden, K. (2007). Enhancing patient safety in nursing education through patient simulation. In R. G. Hughes (Ed.), Patient safety and quality: An evidence-based handbook for nurses (pp. 13641403). Rockville, MD: U.S. Department of Health and Human Services, Retrieved September 24, 2010, from. http://www.ahrq.gov/qual/ nurseshdbk/nurseshdbk.pdf. Haskvitz, L. M., & Koop, E. C. (2004). Students struggling in clinical? A new role for the patient simulator. Journal of Nursing Education, 43(4), 181-184, http://www.journalofnursingeducation.com. Henneman, E. A., Cunningham, H., Roche, J. P., & Cumin, M. E. (2007). Human patient simulation: Teaching students to provide safe care. Nurse Educator, 32(5), 212-217, doi:10.1097/01.NNE.0000289379.83512.fc. Hovancsek, M. (2007). Using simulation in nurse education. In P. R. Jeffries (Ed.), Simulation in nursing education: From conceptualization to evaluation (pp. 1-9). New York: National League for Nursing. Jeffries, P. (2005). A framework for designing, implementing and evaluating simulations used as teaching strategies in nursing. Nursing Education Perspectives, 26(2), 96-103, http://www.nlnjournal.org. Lasater, K. (2007). Clinical judgment development: Using simulation to create an assessment rubric. Journal of Nursing Education, 46(11), 496-503, http://www.nlnjournal.org. McKenna, L., French, J., Newton, J., & Cross, W. (2007). Prepare nurses for the future: Identify use of simulation and more appropriate and timely clinical placement to increase clinical competence and undergraduate positions: Final report of key activities for Department of Human Services nurse policy branch, Victoria, Australia. Melbourne, Australia: Monash University. Murray, C., Grant, M. J., Howarth, M. L., & Leigh, J. (2008). The use of simulation as a teaching and learning approach to support practice learning. Nurse Education in Practice, 8(1), 5-8, Retrieved from http://www.nurseeducationinpractice.com. 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, Retrieved from http://www.professionalnursing.org.
pp e169-e175 Clinical Simulation in Nursing Volume 8 Issue 5
Integrating Simulation Innovatively
e175
Nehring, W. M., Ellis, W. E., & Lashley, F. R. (2001). Human patient simulators in nursing education: An overview. Simulation & Gaming, 32(2), 194-204. doi:10.1177/104687810103200207. O’Donnell, J., Fletcher, J., Dixon, B., & Palmer, L. (1998). Planning and implementing an anesthesia crisis resource management course for
student nurse anesthetists. CRNA: The Clinical Forum for Nurse Anesthetists, 9, 50-58, Retrieved from http://www.ncbi.nlm.nih.gov. Wilford, A., & Doyle, T. (2006). Integrating simulation training into the nursing curriculum. British Journal of Nursing, 15(17), 926-930, Retrieved from http://www.britishjournalofnursing.com.
pp e169-e175 Clinical Simulation in Nursing Volume 8 Issue 5
www.elsevier.com/locate/ecsn
Featured Article
Integrating Simulation Innovatively: Evidence in Teaching in Nursing Education Linde J.B. Wolfgram, RN, MSN*, Annette O’Leary Quinn, RN, MSN, APNP Waukesha County Technical College, Pewaukee, WI 53072, USA KEYWORDS associate degree nursing program; curriculum integration; evidence-based; nursing education; simulation learning; outcomes
Abstract: Clinical simulation has been shown to enhance nursing education. This article is a case summary of one associate degree college’s experience with simulation and describes learning outcomes in eight nursing courses after the inclusion of simulation in the curriculum. It also describes other applications of simulation prompted by faculty and student needs. Our experience showed higher skill scores and greater reported student comfort and confidence in clinical settings after participation in simulation. Simulation, when used as a learning strategy in theory courses, has generally resulted in increases in theory examination scores of 2.5% or greater. A Capstone project in the college’s simulation center in the final nursing semester is described. Medical Education Technologies Incorporated (METIÒ) and GaumardÒ simulators and evidence-based simulated clinical experiences were used in our simulation center. Cite this article: Wolfgram, L. J.B., & Quinn, A. O. (2012, May/June). Integrating simulation innovatively: Evidence in teaching in nursing education. Clinical Simulation in Nursing, 8(5), e169-e175. doi:10.1016/ j.ecns.2010.09.002. Ó 2012 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
Review of the Literature This article is a case report of one college’s experience with simulation and it presents how simulation is embedded into each of the four semesters of our program. The Office of College Advancement at Waukesha County Technical College has reviewed and approved this case report. A perusal of the literature shows that nursing education has been using simulation for more than a century, with high-fidelity simulators being used in the past decade. The computerized technology of the manikin, along with a realistic setup of the environment, creates interactive patient situations to promote skill and knowledge building. Simulation provides active learning and helps students manage anxiety and increase selfassurance and skill level. It provides a positive learning * Corresponding author: [email protected] (L. J.B. Wolfgram).
experience for novices. Simulation has been used as a teaching adjunct and as a substitute for clinical hours (Fowler-Durham & Alden, 2007). It promotes spontaneous and active thinking: thinking ‘‘on the fly’’ in changing situations. Numerous articles and studies in the nursing literature support the use and herald the benefits of high-fidelity computerized manikins in undergraduate nursing education (Bearnson & Wiker, 2005; Bremner, Aduddell, Bennett, & VanGeest, 2006; Broussard, Myers, & Lemoine, 2009; Brown, 2008; Jeffries, 2005; Wilford & Doyle, 2006). Simulators allow students to improve their level of confidence, decision-making skills, and ability to think critically (Nehring, Ellis, & Lashley, 2001). This type of learning also allows students to make errors in a sheltered, safe environment (Fowler-Durham & Alden, 2007; O’Donnell, Fletcher, Dixon, & Palmer, 1998). Knowledge and communication skills are improved with simulation use, as are interdisciplinary teamwork and
1876-1399/$ - see front matter Ó 2012 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
doi:10.1016/j.ecns.2010.09.002
Integrating Simulation Innovatively
e170
interpersonal and psychomotor skills (Lasater, 2007). Simulation can aid the nursing student in applying theoretical concepts to clinical presentations and contexts and narrow this integration gap. Because of increasing patient acuity in inpatient settings, students must come to the clinical site better able to deal with rapidly changing situations Key Points and greater technological The ADN program at interventions. Improved Waukesha County decision-making abilities Technical College and greater awareness of pahas embedded simutient safety have been demlation learning using onstrated with the use of evidence-based data simulation and quality deinto the nursing briefing (Henneman, curriculum. Cunningham, Roche, & The use of simulation Cumin, 2007). is described at each A systematic review of level of the student’s this method of learning in education. nursing education supports Other simulation apthe belief that simulation is plications, unique exan effective and valid learnperiences unavailable ing and teaching strategy to students in clinical (Cant & Cooper, 2009). Stusettings and a descripdents have the opportunity tion of the final semesto participate in high-acuity, ter Capstone project low-frequency situations in are provided. a simulated environment. They have the ability, as students, to be directly involved with skills and tasks that may be denied to them or simply not presented in a clinical setting (e.g., telephoning a health care provider for orders, administering blood products, and dealing with cardiac arrest situations). Students have the chance to repeatedly practice working with fast-paced, emergent, and highstress situations in a realistic, yet simulated, environment. Simulation strives to reproduce essential aspects of clinical situations in order that these circumstances can be more easily managed and better understood in the real setting (Hovancsek, 2007). Wilford and Doyle (2006) have combined Miller’s pyramid model of competence in skill learning with simulation learning to illustrate improvement in ability, proficiency, and confidence. Simulation has been used as a remediation tool with nursing students to allow for multiple opportunities in order to ensure proficiency in routine assessment or skills (Haskvitz & Koop, 2004). Undergraduate nursing curricula across the world have embraced and widely incorporated this teaching and learning tool (McKenna, French, Newton, & Cross, 2007; Murray, Grant, Howarth, & Leigh, 2008; Nehring, 2008). One study (Brannan, White, & Bezanson, 2008) has shown simulation is a superior teaching tool to effect knowledge, critical thinking, and confidence, particularly in comparison with classroom lecture techniques. This literature review supports the effectiveness of simulation in a teachingelearning environment.
Program History and Description Waukesha County Technical College (WCTC) officially opened the Human Patient Simulator (HPS) Center on May 1, 2007. Prior to the opening of the lab, other simulation centers in the area were toured. Conversations were held with faculty and staff at these centers to explore reasons for success and to discuss potential and actual problems. This expertise was used in the design and organization of our simulation center. Funding from a U.S. Department of Labor grant allowed the purchase of two Medical Education Technologies (METIÒ) simulators, a high-fidelity adult and a pediatric emergency care simulator. There is a dedicated full-time simulation technician for the lab and assigned faculty equivalent to one full-time position. Funding for those positions initially came from the Department of Labor grant but now has been incorporated into the nursing department’s budget. WCTC faculty’s and administration’s experience has been that these positions are critical to the high usage and success of our program, and they have therefore been made part of the operating budget. A Gaumard birthing simulator was added, and the Emergency Medical Services department has a Laerdal adult simulator in the HPS Center. Our nursing department also purchased METI’s Program for Nursing Curriculum Integration (PNCI) product. The PNCI consists of more than 90 written and preprogrammed evidence-based simulated clinical experiences (SCEs) for use with the infant, pediatric, or adult simulators. Each SCE includes a learner and faculty guide. Integration of simulation into our nursing curriculum began immediately with clinical make-up and open lab sessions. In the fall of 2007, clinical and skills courses dedicated student time in the HPS Center, emphasizing difficult course content or high-acuity clinical situations. All WCTC clinical and theory faculty use simulation methodology. Typical faculty usage is 4 hours every semester. This is a combination of clinical hours and theory hours. The nursing department has seen a great increase in student usage since the opening, as shown in Figure 1. Between the fall of 2007 and the spring of 2009, WCTC’s nursing program averaged 200 students in total. In the fall of 2007, 273 students participated in 819 hours of simulation. Students participate in multiple simulation experiences throughout the semester. In the spring of 2009, 793 students (same students attend multiple simulation sessions) participated in 2,250 hours of simulation. In addition, our simulation center ran 55 scenarios in the fall of 2007, and that increased to 116 scenarios in the spring of 2009. Scenarios are repeated as faculty and students require. The nursing program at WCTC is divided into four semesters for the full-time associate degree in nursing (ADN) student.
First Semester In the first semester of our four-semester nursing program, full-time nursing students must complete three theory
pp e169-e175 Clinical Simulation in Nursing Volume 8 Issue 5
Integrating Simulation Innovatively
e171 WCTC - HPS Center Utilization
2500
2232
2250
2205
2000
Student Hours
1500
Students
1000
Simulated Scenarios
819
744
735
793
500 273 55
115
100
116
0 Fall 2007 Figure 1
Spring 2008
Fall 2008
Spring 2009
Waukesha County Technical College Human Patient Simulator Center use.
courses and one 90-hour clinical course. One of these theory courses is a nursing skills class, in which physical assessment techniques are taught. This course concludes before the clinical course begins, and a student must demonstrate a competent head-to-toe physical assessment in this skills course before advancing to the clinical course. This demonstration is a graded performance in the skills class curriculum. To accompany didactic content, an optional 2-hour physical assessment open lab simulation experience is offered to students. In this lab, physical assessment skills are practiced by students in the presence of an instructor. It is not a mandatory part of class because of curriculum time constraints. The student-to-faculty ratio is 8:1, and three simulators are available for students. The physical assessment open lab was heavily promoted by faculty and enjoyed a good reputation among students and over two semesters, fall 2008 and spring 2009; 93% (89 of 96) of the students in the skills class attended the open lab. The seven students who did not attend all reported a schedule conflict that prevented their attendance. The physical assessment simulation labs were facilitated by one faculty member, who was also an instructor in the skills class and would be one of five faculty grading the physical assessment in the skills theory course. To determine whether the additional experience of attending a physical assessment simulation lab would affect the physical assessment graded skills performance scores, we gathered data from the rubric used by the faculty of the skills course (see Online Extra Appendix 1 at www.nursingsimulation.org). A scale of 1 through 5 was used in the rubric, with 3.95 being a passing score of 79%. The 79% is a predetermined pass rate for the Department of Nursing at WCTC. As shown in the
grading rubric, a score of 5 meets all criteria. The average score for the 89 students who attended the simulation was 4.91 out of 5, which we compared with the average score (4.79 out of 5) of 94 students who did not have the physical assessment simulation lab option in the fall of 2007 and the spring of 2008. In addition to comparing scores of these two groups of students, we asked a question of clinical faculty. The question was, ‘‘Did you observe an improvement in performance in the students’ head-to-toe assessment in clinical practice? Please comment.’’ The faculty reported observing more accuracy and confidence being demonstrated in clinical practice by the students who had attended the physical assessment simulation lab. Additionally, during the first semester, one 5-hour day of an 18-day clinical medicalesurgical rotation (approximately 5.5% of total clinical time) is spent practicing simulation with a medicalesurgical scenario. Nursing instructors work with their own clinical students in simulation and can adjust the scenario to resemble the specific hospital setting where the students will be practicing. Student feedback about this experience is obtained through a course evaluation question: ‘‘Were your clinical experiences positively affected by the day spent in simulation?’’ This question was answered via a 5point Likert-type scale, and 80 out of 96 students (83%) responded with a score of 5 (exceeded expectations) or 4 (met expectations). The other points along the Likert-type scale included 3 (expectations partially met), 2 (expectations rarely met), and 1 (expectations not met) All narrative comments by students were highly positive toward the experience. Many students stated that they felt they could move ‘‘up to speed’’ more quickly in clinical because unit-specific policies and instructor expectations were clearly defined during an initial simulation experience.
pp e169-e175 Clinical Simulation in Nursing Volume 8 Issue 5
Integrating Simulation Innovatively
e172
Health Promotions Course Evaluations 20 Students
12 6
1
Figure 2
0
1
Health promotions course evaluations, 20 students.
Second Semester During the second semester of our nursing program, didactic content on obstetrical, neonatal, and mental health nursing is a part of our health promotion course. An obstetrical clinical course and a mental health clinical course occur concurrently with this didactic course. Faculty in the health promotion course felt that simulation would enhance learning beyond classroom discussion. A decision was made to include two required simulation experiences. These instructors were able to incorporate these simulation experiences into classroom time or clinical time. For the labor and delivery content, clinical preparation is held in our simulation center, making use of the program’s birthing manikin, and is facilitated by women’s health faculty. This is a 2-hour experience that occurs 1 day before the obstetrical clinical rotation begins. Content that includes nursing assessment and care in the neonate and newly delivered mother is built into a basic simulation scenario using the newborn and birthing manikins. A group of four students cares for simulated patients who have had a vaginal or cesarean delivery. Students are required to provide a postpartum assessment and basic newborn teaching for the simulation mothers. Because student perception is positively associated with confidence levels, perception of value was evaluated at the end of the semester. During the health promotion course evaluation, the question was asked, ‘‘Did the labor, delivery, newborn simulation meet your expectations in learning this content?’’ Using a 5point Likert-type scale, 18 out of 20 students (90%) in the spring 2009 semester rated this experience with a 5 (exceeded expectations) or 4 (met expectations). The other points on the Likert-type scale included 3 (expectations partially met), 2 (expectations rarely met), and 1 (expectations not met). See Figure 2. Narrative comments were all positive; for example, ‘‘I felt more prepared to care for my patients on the postpartum unit.’’ To augment our neonatal curriculum, a respiratory distress syndrome and septic baby syndrome are offered for students. These are offered as optional simulation labs and are not offered during normal class time. Of the total class, 8 out of 20 students (40%) took advantage of this opportunity in the spring 2009 semester. For the students who
participated in these simulations, theory test scores on four questions targeting respiratory distress or neonatal sepsis averaged 87.5% correct, compared with 85% from those who did not attend the simulations. The difference in test score averages is not statistically significant. When students were informally asked why they chose not to participate in optional labs, they cited time and schedule constraints. It could also be theorized that students who have time to attend optional simulations also have more time to study, and that could contribute to higher test scores. As the use of simulation evolves in our nursing program, certain simulations will have a mandatory attendance requirement. However, it is anticipated that optional simulation attendance will continue to meet some learners’ needs. In 2007, our program recognized the need for mental health scenarios and developed an alcohol withdrawal SCE. Our second-semester students spend 1 clinical day (5 hours) participating in this SCE as part of their mental health clinical course. Anecdotal student feedback has been consistently positive regarding this experience, and reported student comfort level at clinical sites caring for this patient population has improved.
Third Semester The third semester of our program includes two clinical rotations, an acute care setting and a community-based setting (urgent cares, day surgeries, school settings, and gastrointestinal or cancer centers). The theory components include a complex health alterations course, an advanced nursing skills course, and a mental health course. At the third level of our program, students work through either a pediatric fluid and electrolyte or a diabetic ketoacidosis SCE. This SCE strengthens fluid and electrolyte knowledge and provides students with much needed pediatric opportunities. For the spring 2009 semester, 38 out of 45 students (84%) agreed or strongly agreed that the HPS lab provided scenarios that gave a better understanding of pathophysiology and medications. In fall 2008, 33 out of 38 students (87%) positively rated increased confidence from HPS experiences in decision-making and assessment skills. This information was gathered from student selfreported anonymous surveys completed at the end of the semester. The course evaluations consist of 12 questions, 2 of which are directly related to simulation experience in the course (see Online Extra Appendix 2 at www. nursingsimulation.org). Comments from both semesters included ‘‘have more HPS sessions’’ and ‘‘have an additional day in HPS.’’ In our third-level advanced skills course, each student was required to attend a blood administration and transfusion reaction scenario to practice, through simulation, the process of blood verification and prompt recognition of and response to an adverse reaction. Test content statistics are tracked for every written examination. Correct answers on theory test
pp e169-e175 Clinical Simulation in Nursing Volume 8 Issue 5
Integrating Simulation Innovatively
e173
content related to blood administration increased from an average of 86% prior to student simulation use to an average of 90.3% when students attended simulation. Student feedback from this simulation has been extremely positive.
Fourth Semester In the final semester of our ADN program, students have 229 clinical hours during 14 weeks in an acute care setting. Concurrently, students have another complex health alterations course and a management and professional concepts theory course. At the fourth level of our program, clinical competency is assessed in a final, capstone project. In the 4 weeks before graduation, a student nurse is expected to care for a patient having a typical medicalesurgical inpatient experience. To help the students prepare for this graded project, a capstone preparation day is required. With minimal faculty guidance, four students are assigned simulation roles (primary nurse, medication nurse, resource nurse, and documentation nurse) and then care for a simulated patient for 2 hours. Students have commented that this preparation day has decreased anxiety and increased learning and confidence. Students also participate in an hour-long session the week of capstone to again become familiar and comfortable with the simulated environment, the location of supplies, the medication cart, and the manikin itself. Students have remarked that being able to tour the space just prior to this graded experience has greatly lowered anxiety. For the graded capstone simulation, the student is given report on a patient and a set of orders to be completed. An SCE from METI’s PNCI scenario list, modified by the clinical instructor, is selected. Modifications have included the addition of skills, addition of parenteral medications, and minor changes to provider orders or assessment findings. These scenarios are dedicated solely to the capstone project, and students have never encountered these specific scenarios during their previous simulation experiences. In real time, the student is expected to competently and efficiently complete care for this patient. A detailed rubric is used by faculty to evaluate students (see Online Extra Appendix 3 at www. nursingsimulation.org). This rubric was developed by one of the college’s nursing faculty, Beth Connell-Weiand, MSN, APN, MSHA. The rubric links critical course competencies and minimal expected observable behaviors. METIÒ’s listed minimal expected behaviors from the PNCI scenario are used. The rubric contains 100 points, and each student is evaluated on skill performance, leadership ability, communication, critical thinking, and safety. Faculty evaluators, who are also the clinical faculty for students, have commented that simulation performance for marginal students mirrored performance in clinical. A score of 79% or higher on the rubric is considered successful. HPS capstone projects have been in place for four semesters, 118 students have participated, and
5 (4%) have been unsuccessful. Reasons for failure include the student’s inability to recognize his or her own unsafe behavior; inability to prioritize, manage care, and think critically; or inability to perform nursing skills competently. In spring 2009, HPS sessions were incorporated into the second Complex Health Alterations course in order to reinforce content identified as difficult by students and faculty. These areas included pregnancy-induced hypertension; shock (septic and neurological); and hepatic, gastrointestinal, and renal concepts. Students were required to attend one scenario focusing on one of these content areas, facilitated by course faculty. Test scores on all assessed content areas except pregnancy-induced hypertension and renal improved with implementation of this requirement, increasing by between 2.6% and 7.4%. All examination scores were tracked and evaluated. It is postulated that both content areas are very challenging. However, students reported the HPS experiences for this course as ‘‘a great help’’ and ‘‘also helpful.’’ At the conclusion of our program, students are required to attend a graduate feedback conversation. This is led by a facilitator from our college’s Center for Quality and Innovation, without the presence of nursing faculty. This conversation lasts from 1 to 2 hours, and students are asked a variety of questions about their educational experience, including the most valuable aspect of their education, nonvaluable educational events, and memorable faculty experiences. Students provide written comments and also verbal comments, which are transcribed by the facilitator. Information is provided to the faculty after the completion of the semester and the submission of course grades. Student comments about the HPS Center at the completion of their academic experience included, ‘‘HPS Lab was a great learning experience,’’ ‘‘I enjoyed all the HPS experiences,’’ ‘‘HPS continues to be helpful,’’ ‘‘I would like more HPS experiences,’’ and ‘‘HPS was a great tool for learning.’’ More than 90% of the student comments were positive about the HPS lab and simulated experiences.
Other Simulation Applications At WCTC, our simulation also provides the following skill experiences, in which students would not be allowed to participate in clinical practice. For example, because of state licensing laws, nursing students are not allowed to independently call health care providers for verbal orders. Also, nursing students are not allowed to open automated drug dispensing units for narcotic or house stores of medications. Both of these situations are embedded in simulations so that students can become comfortable with these experiences before graduation. Across the curriculum, clinical makeup sessions are available to students. Faculty recognizes this as a rigorous and realistic substitution for missed clinical time. These makeup sessions are offered every 4 weeks throughout the
pp e169-e175 Clinical Simulation in Nursing Volume 8 Issue 5
Integrating Simulation Innovatively
e174
semester in order to meet student needs on a timely basis. Students are permitted to miss 2 clinical days per clinical course each semester. Simulation sessions are used to meet the lost hours. In our program, if a student misses more time, hours are made up at the clinical settings or the student withdraws from the course and reenters at a later date. The state of Wisconsin has regulated the number of clinical hours per semester and per program but at this time has not formulated a policy for clinical hours coming from simulation. We have been fortunate that in our geographic location, severe clinical site shortages have not occurred. Open labs are also offered to complement theory content and to meet student requests. For example, fourth-level students have requested a labor and delivery review before their pre-National Council Licensure Examination (NCLEX) test. Mock code simulations are offered once per semester and are very popular. Open labs are not mandatory, and students receive a certificate of attendance to augment their nursing portfolios. Attendance is determined solely by the interest and the initiative of the student. When students were surveyed regarding helpful support services, the HPS lab ranked second out of 12 collegewide services. The nursing developmental skills lab and skills review sessions were listed by students as the No. 1 support service. In addition, students in the upper levels of the program who have been unsuccessful in a clinical course may be required to perform a simulation skills mastery scenario in order to reenter clinical. Adequate practice time is allowed, and students work with a faculty member in the simulation lab and complete nursing cares and an order set for a patient. The student is permitted two attempts and is evaluated by a faculty member for the HPS skills mastery sessions.
Conclusion Clinical simulation has enhanced our students’ nursing education experience and has been embraced by our faculty. The success of the program has been due in part to administrative support in funding faculty hours in simulation, as well as in funding a full-time simulation technician manager. Our state board pass rates vary between 90% and 95%, with a student retention rate in the 70th percentile. Prior to the introduction of simulation, our retention rates were in the 40th percentile. Our NCLEX pass rates have been consistently first or second in our state. WCTC is one of 5 technical schools in the 16-school Wisconsin Technical system to have introduced simulation into the nursing curriculum. As faculty, we believe that part of our success rate with retention and consistently strong NCLEX scores can be attributed to simulation learning and our students’ positive quantitative and anecdotal response to this teaching strategy. Our future simulation plans include increased simulation use in theory didactic courses, by means of tetherless, portable simulators brought into the classroom. In response to student requests, review
simulations outside the calendar year (i.e., during summer and winter breaks) will be added. Review simulations include scenarios featuring high level and demanding nursing skills and scenarios focusing on prioritization and critical thinking. The introduction and integration of simulation learning has been well received by both faculty and students in our ADN program.
References Bearnson, C., & Wiker, K. (2005). Human patient simulators: A new face in baccalaureate nursing education at Brigham Young University. Journal of Nursing Education, 44(9), 421-425, http://www. journalofnursingeducation.com. Brannan, J., White, A., & Bezanson, J. (2008). Simulator effects on cognitive skills and confidence levels. Journal of Nursing Education, 47(11), 495-500, doi:10.3928/01484834-20081101-01. Bremner, M., Aduddell, K., Bennett, D., & VanGeest, J. (2006). The use of human patient simulators: Best practices with novice nursing students. Nurse Educator, 31(4), 170-174, doi:10.1097/00006223-20060700000011. Broussard, L., Myers, R., & Lemoine, J. (2009). Preparing pediatric nurses: The role of simulation-based learning. Issues in Comprehensive Pediatric Nursing, 32, 4-15, doi:10.1080/01460860802610178. Brown, J. F. (2008). Applications of simulation technology in psychiatric mental health nursing education. Journal of Psychiatric and Mental Health Nursing, 15, 638-644, doi:10.1111/j.1365-2850.2008.001281.x. Cant, R. P., & Cooper, S. J. (2009). Simulation-based learning in nurse education: Systematic review. Journal of Advanced Nursing, 66(1), 3-15, doi:10.1111/j.1365-2648.2009.05240.x. Fowler-Durham, C., & Alden, K. (2007). Enhancing patient safety in nursing education through patient simulation. In R. G. Hughes (Ed.), Patient safety and quality: An evidence-based handbook for nurses (pp. 13641403). Rockville, MD: U.S. Department of Health and Human Services, Retrieved September 24, 2010, from. http://www.ahrq.gov/qual/ nurseshdbk/nurseshdbk.pdf. Haskvitz, L. M., & Koop, E. C. (2004). Students struggling in clinical? A new role for the patient simulator. Journal of Nursing Education, 43(4), 181-184, http://www.journalofnursingeducation.com. Henneman, E. A., Cunningham, H., Roche, J. P., & Cumin, M. E. (2007). Human patient simulation: Teaching students to provide safe care. Nurse Educator, 32(5), 212-217, doi:10.1097/01.NNE.0000289379.83512.fc. Hovancsek, M. (2007). Using simulation in nurse education. In P. R. Jeffries (Ed.), Simulation in nursing education: From conceptualization to evaluation (pp. 1-9). New York: National League for Nursing. Jeffries, P. (2005). A framework for designing, implementing and evaluating simulations used as teaching strategies in nursing. Nursing Education Perspectives, 26(2), 96-103, http://www.nlnjournal.org. Lasater, K. (2007). Clinical judgment development: Using simulation to create an assessment rubric. Journal of Nursing Education, 46(11), 496-503, http://www.nlnjournal.org. McKenna, L., French, J., Newton, J., & Cross, W. (2007). Prepare nurses for the future: Identify use of simulation and more appropriate and timely clinical placement to increase clinical competence and undergraduate positions: Final report of key activities for Department of Human Services nurse policy branch, Victoria, Australia. Melbourne, Australia: Monash University. Murray, C., Grant, M. J., Howarth, M. L., & Leigh, J. (2008). The use of simulation as a teaching and learning approach to support practice learning. Nurse Education in Practice, 8(1), 5-8, Retrieved from http://www.nurseeducationinpractice.com. 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, Retrieved from http://www.professionalnursing.org.
pp e169-e175 Clinical Simulation in Nursing Volume 8 Issue 5
Integrating Simulation Innovatively
e175
Nehring, W. M., Ellis, W. E., & Lashley, F. R. (2001). Human patient simulators in nursing education: An overview. Simulation & Gaming, 32(2), 194-204. doi:10.1177/104687810103200207. O’Donnell, J., Fletcher, J., Dixon, B., & Palmer, L. (1998). Planning and implementing an anesthesia crisis resource management course for
student nurse anesthetists. CRNA: The Clinical Forum for Nurse Anesthetists, 9, 50-58, Retrieved from http://www.ncbi.nlm.nih.gov. Wilford, A., & Doyle, T. (2006). Integrating simulation training into the nursing curriculum. British Journal of Nursing, 15(17), 926-930, Retrieved from http://www.britishjournalofnursing.com.
pp e169-e175 Clinical Simulation in Nursing Volume 8 Issue 5