- Email: [email protected]
Simulation Workshop in Pan-America: Lessons Learned
Clinical Simulation in Nursing (2012) 8, e177-e180
www.elsevier.com/locate/ecsn
Featured Article
Simulation Workshop in Pan-America: Lessons Learned Laura Gonza´lez, PhD, ARNP, CNE* University of South Florida, Tampa, FL 33612, USA KEYWORDS barriers; international; simulation
Abstract: Simulation in nursing has gained international prominence. While Europe and Asia have made significant advances in simulation in nursing, the Pan-American countries have struggled with limited financial resources and geographic barriers, to name a few issues. This article details one faculty member’s experiences hosting the first preconference simulation workshop at La Asociacion Latino Americano de Educacion en Enfermeria in the city of Panama. The University of South Florida cosponsored a nursing workshop in the fall of 2009. Participants included 31 nurses. Our PanAmerican colleagues embrace simulation technology and are eager for ongoing workshops. Discussion is needed to identify ways to help our nursing colleagues in Latin America seek funding sources and potential collaborators to further develop their simulation initiatives in nursing education. Cite this article: Gonza´lez, L. (2012, May/June). Simulation workshop in pan-america: Lessons learned. Clinical Simulation in Nursing, 8(5), e177-e180. doi:10.1016/j.ecns.2010.08.004. Ó 2012 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
Simulation is recognized as a strategy that develops psychomotor and critical thinking skills in nursing students to produce competent care providers (Rauen, 2001). Simulation has gained a foothold in most schools of nursing in the United States, Europe, and Asia (Nehring & Lashley, 2004). Universities are embracing simulation technology to provide technical clinical nursing skills and critical thinking exercises (Hovancsek et al., 2009). Likewise, the Institute of Medicine (2004) reports that simulation can close the gap between didactic and clinical experiences, providing a more seamless transition to the role of the professional nurse. Using simulations requires a major commitment on the part of an institution. On average, a patient simulator, adult or pediatric model, costs between
* Corresponding author: [email protected] (L. Gonza´lez).
US$28,000 and US$170,000 or more, depending on functionality and degree of autonomous operation (Metcalfe, Hall, & Carpenter, 2007). Total costs to maintain and implement a full-service simulation laboratory can range between US$250,000 and US$1.6 million (Touriniemi & Schott-Baer, 2008). The University of South Florida (USF) College of Nursing has been using both low-fidelity and high-fidelity simulation as a teaching strategy for approximately 5 years. Simulation has been implemented successfully across five semesters in the undergraduate curriculum major content areas, including fundamentals, medicalesurgical nursing, pediatrics, obstetrics, and community health courses. The simulation team at USF is made up of nursing faculty in all the major content areas, such as adult health, maternale child health, and fundamentals. The team is headed by the director of simulation, who oversees all simulations,
1876-1399/$ - 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.2010.08.004
Simulation Workshop
e178
content, logistics, and outcomes. Simulation is introduced early in fundamentals and woven throughout the five semesters. Student evaluations are overwhelmingly positive, and there has been ongoing adoption throughout the curriculum. Efforts have been made to share current nursing Key Points technologies with other na There is interest tions. In 2004, Nehring and abroad for ongoing Lashley surveyed schools of simulation education nursing in Australia, Enin nursing. gland, New Zealand, and Opportunities for colGermany on their perceplaboration exist. tions of simulation as Geographic distance a teaching strategy. From and patriarchal sentithe findings it was evident ment pose barriers to that most schools of nursing simulation in nursing. are still formulating ways to better enhance their curriculum with learning through simulation. Additionally, the cost of high-fidelity simulation equipment is a drawback; it was recommended that schools organize and develop nursing simulation centers to meet regional needs. The results from this survey were limited, and there was no representation from Latin American schools of nursing. Most recently the National League for Nursing has embarked on the development of a Simulation Innovation and Resource Center (Hovancsek et al., 2009), which is a collaborative effort of nurse educators from abroad to include countries as far away as Chile. As a result of the initiative, the National League for Nursing has developed online learning modules on the use of simulation for faculty to access globally. As simulation becomes more widespread, there is a burgeoning need to formalize and share perspectives. The Simulation Innovation and Resource Center acts as a center for simulation scenarios and interactive activities that can be shared with international educators. This grant was sponsored by Laerdal Medical Corporation, the maker of the patient simulator SimManÒ. To date the only Latin American country involved in this collaborative is Chile. While this is a promising start, there needs to be better representation from Latin American institutions in the collaborative. In light of these findings, opportunities abound for collaboration with our Latin American nursing colleagues. Development of regional simulation centers may meet the need of nursing schools in this time of restricted resources.
Global Initiatives at USF USF, as part of its global initiative, has a working relationship with the country of Panama. For approximately 5 years, USF undergraduate nursing students have had the opportunity to travel to Panama as part of the community health elective. Students are immersed in the Panamanian
culture by being paired with host students, living with families, and participating in the daily activities of the Panamanian people. On arrival in Panama, students are assigned to rural clinical sites that are typically several hours away from the capital. Overall clinical experiences vary but include well-woman checkups, healthy children visits, births, vaccinations, and the development of educational initiatives in consultation with local nurses. USF nursing students pay to participate in this clinical experience. The fees cover airfare, room, and living expenses. In addition, students register for a 4-credit clinical course; nursing students at USF are required to earn 124 credit hours in order to graduate with a baccalaureate in nursing. A faculty member travels with the students and oversees the clinical requirements.
Breaking Barriers to Simulation in Pan-America: A University Initiative As a consequence of this well-established relationship, in the fall of 2009 USF faculty cohosted with the University of Panama the first preconference workshop on simulation, titled Integration of Simulation Across a Nursing Curriculum. The nursing conference, La Asociacio´n Latino Americano de Educacio´n en Enfermerı´a, is an annual nursing conference attended by hundreds of Latin American nurses from as far away as Chile and Peru. The purpose of this article is to detail one USF faculty member’s experience of hosting a simulation workshop in Panama and to illustrate the need to assist our Latin American colleagues in the adoption of simulation as a teaching strategy. As cohosts of the preconference, faculty members were asked to develop a preconference workshop for participants. It was decided that the workshop would consist of two half-day workshops with both a didactic and a handson component. The content and all the materials were developed in Spanish. Registration was handled through the office of continuing professional education at USF. The cost for the workshop was US$20 per delegate and covered snacks and materials. Faculty travel and attendance were paid for by a small internal grant through the office of International Studies of Latin American Countries. The conference was held at the University of Panama, located in the city of Panama. The University of Panama is the public university for the country and has one of Panama’s nursing programs. The simulation preconference workshop was held at Universidad Latina, which is a private school of medicine and nursing in the city of Panama. It has a well-equipped simulation laboratory, which is used predominantly by the physicians and medical students. The laboratories have a SimManÒ (Laerdal), NOELLEÒ (Gaumard), several VitalSimsÔ (Laerdal), and live streaming video and audio capability. There are two full-time staff members responsible for the development and integration of simulated experiences. Marketing and advertisement of
pp e177-e180 Clinical Simulation in Nursing Volume 8 Issue 5
Simulation Workshop
e179
the workshop were handled by the Universidad Latina in conjunction with the University of Panama. Materials for the workshop were developed with the National League for Nursing’s Simulation in Nursing Education: From Conceptualization to Evaluation (Jeffries, 2007) as a template. It was supplemented by the presenters’ personal experience and expertise in simulation. All materials were provided to attendees at the beginning of the workshop both as paper handouts and in an electronic format in the form of a hyperlink. Thirty participants registered and attended the workshop. Most attendees spoke no English. Attendees were either nursing faculty or staff nurses, in most instances both there was one physician in attendance. There was a tremendous sense of camaraderie; all attendees were engaged and asked thoughtful questions during the didactic portion. After the didactic session, participants were asked to move into the laboratory, where the simulated experiences occurred. Prior to the simulation, all participants were oriented to the simulator’s features. The format used was an unfolding case scenario, with a primary nurse caring for the patient and the other attendees observing and critiquing. Time was allotted for questions, answers, and debriefing. Very few of the participants had any previous experience with this type of simulation. Participants had differing perspectives in relation to simulation; many of the participants did not realize how powerful simulation as a teaching strategy could be. Some indicated that they wished this technology had been available when they were students. All participants recognized the value of interdisciplinary simulation as a way to improve communication among physicians, nurses, and members of the health care team. However, when queried about the potential for future workshops, most described lack of resources as a barrier to continuing education. Participants were quick to point out how much they appreciated the workshop being presented in their native language. It is not uncommon to find English-speaking presenters at foreign conferences, and at times the attendees may feel resentful that an effort was not made to present in their native language. Speaking Spanish afforded the presenter the opportunity to quickly build rapport with the attendees. Issues that should be considered for future events include the perception of time. Latinos often have a different perception of time orientation (Marin & VanOss-Marin, 1991). Both sessions started very late because attendees did not arrive at the expected time. Attendees typically showed up 30 minutes late to the session. This created an issue for the presenter. When queried about reasons for being tardy, most participants mentioned the long distances they drove in order to attend the workshop, 5 hours in some instances. Another issue was the perception that simulation was used only to teach psychomotor skills such as catheter insertion and wound care management, as opposed to case development and critical thinking application, which is common with the use of high-fidelity simulation in the United States.
Expensive simulators are not necessary to run highly realistic scenarios. In fact, with some creativity, a mid-fidelity simulator and task trainer work as well. At the Universidad Latina, simulation is used predominantly with medical students with medical students, while nursing students use simulation as an opportunity for skill attainment. The idea of developing scenarios for teaching was novel and not a strategy faculty members were particularly familiar with. For many of the participants, the use of simulation in their curriculum or as part of staff development will never be realized as very little is available for the purchase of such expensive equipment. Likewise, grants and endowments are lacking among the Pan-American institutions. One of the major distributors of the patient simulators does not have representation in Pan-America as interest and ability to purchase such expensive equipment is limited. Ongoing discussion is needed to assist our colleagues in finding available funding sources and potential partnerships with universities in the United States.
Conclusion The attendees of the preconference workshop were excited and enthusiastic about simulation. Nursing faculty in PanAmerican schools of nursing are just now recognizing the power of simulation as a teaching strategy. However, limited resources and funding have prevented the acquisition of patient simulators for most programs. Patriarchal sentiment and geography are just a few of the barriers to implementing simulation in nursing curricula. The PanAmerican countries would do well to develop a consortium and pool funding sources to create multiprofessional simulation centers that serve geographical areas rather than individual schools of nursing. One idea worth considering is donation of older simulators to a PanAmerican nursing program. In light of current financial constraints, Pan-American countries are unable to provide monetary support or stipends to have experts in simulation present locally. Creative ways are needed to generate funding to sponsor experts in the field of simulation. One way would be to require all the participating universities and health care organizations to pay a small fee for using the multiprofessional simulation centers. A portion of the fees could be used to secure experts in the field of simulation. If we consider local health to be as important as global health, then nursing educators in Pan-America could use the support to bring simulation technology to their institutions in order to enhance teaching strategies and ultimately graduate better prepared nurses.
References Hovancsek, M., Jeffries, P., Escudero, E., Foulds, B. J., Husebo, S. E., Iwamoto, Y., et al. (2009). Creating simulation communities of practice: An international perspective. Nursing Education Perspectives, 30(2), 121-125.
pp e177-e180 Clinical Simulation in Nursing Volume 8 Issue 5
Simulation Workshop
e180
Institute of Medicine. (2004). Keeping patients safe: Transforming the work environment. Washington, DC: National Academies Press. Jeffries, P. (Ed.). (2007). Simulation in nursing education. New York: National League for Nursing. Marin, G., & VanOss-Marin, B. (1991). Research with Hispanic populations (Vol. 33). Newbury Park, CA: Sage. Metcalfe, S. E., Hall, V. P., & Carpenter, A. (2007). Promoting collaboration in nursing education: The development of a regional simulation laboratory. Journal of Professional Nursing, 23(3), 180-183.
Nehring, F. R., & Lashley, W. M. (2004). Current use and opinions regarding human patient simulators in nursing education: An international survey. Nursing Education Perspectives, 25(5), 244-248. Rauen, C. (2001). Using simulation to teach critical thinking skills: You cannot just throw the book at them. Critical Care Nursing Clinic North America, 13, 93-103. Touriniemi, P., & Schott-Baer, D. (2008). Implementing a high-fidelity simulation program in a community college setting. Nursing Education Perspectives, 29(2), 105-109.
pp e177-e180 Clinical Simulation in Nursing Volume 8 Issue 5
www.elsevier.com/locate/ecsn
Featured Article
Simulation Workshop in Pan-America: Lessons Learned Laura Gonza´lez, PhD, ARNP, CNE* University of South Florida, Tampa, FL 33612, USA KEYWORDS barriers; international; simulation
Abstract: Simulation in nursing has gained international prominence. While Europe and Asia have made significant advances in simulation in nursing, the Pan-American countries have struggled with limited financial resources and geographic barriers, to name a few issues. This article details one faculty member’s experiences hosting the first preconference simulation workshop at La Asociacion Latino Americano de Educacion en Enfermeria in the city of Panama. The University of South Florida cosponsored a nursing workshop in the fall of 2009. Participants included 31 nurses. Our PanAmerican colleagues embrace simulation technology and are eager for ongoing workshops. Discussion is needed to identify ways to help our nursing colleagues in Latin America seek funding sources and potential collaborators to further develop their simulation initiatives in nursing education. Cite this article: Gonza´lez, L. (2012, May/June). Simulation workshop in pan-america: Lessons learned. Clinical Simulation in Nursing, 8(5), e177-e180. doi:10.1016/j.ecns.2010.08.004. Ó 2012 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
Simulation is recognized as a strategy that develops psychomotor and critical thinking skills in nursing students to produce competent care providers (Rauen, 2001). Simulation has gained a foothold in most schools of nursing in the United States, Europe, and Asia (Nehring & Lashley, 2004). Universities are embracing simulation technology to provide technical clinical nursing skills and critical thinking exercises (Hovancsek et al., 2009). Likewise, the Institute of Medicine (2004) reports that simulation can close the gap between didactic and clinical experiences, providing a more seamless transition to the role of the professional nurse. Using simulations requires a major commitment on the part of an institution. On average, a patient simulator, adult or pediatric model, costs between
* Corresponding author: [email protected] (L. Gonza´lez).
US$28,000 and US$170,000 or more, depending on functionality and degree of autonomous operation (Metcalfe, Hall, & Carpenter, 2007). Total costs to maintain and implement a full-service simulation laboratory can range between US$250,000 and US$1.6 million (Touriniemi & Schott-Baer, 2008). The University of South Florida (USF) College of Nursing has been using both low-fidelity and high-fidelity simulation as a teaching strategy for approximately 5 years. Simulation has been implemented successfully across five semesters in the undergraduate curriculum major content areas, including fundamentals, medicalesurgical nursing, pediatrics, obstetrics, and community health courses. The simulation team at USF is made up of nursing faculty in all the major content areas, such as adult health, maternale child health, and fundamentals. The team is headed by the director of simulation, who oversees all simulations,
1876-1399/$ - 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.2010.08.004
Simulation Workshop
e178
content, logistics, and outcomes. Simulation is introduced early in fundamentals and woven throughout the five semesters. Student evaluations are overwhelmingly positive, and there has been ongoing adoption throughout the curriculum. Efforts have been made to share current nursing Key Points technologies with other na There is interest tions. In 2004, Nehring and abroad for ongoing Lashley surveyed schools of simulation education nursing in Australia, Enin nursing. gland, New Zealand, and Opportunities for colGermany on their perceplaboration exist. tions of simulation as Geographic distance a teaching strategy. From and patriarchal sentithe findings it was evident ment pose barriers to that most schools of nursing simulation in nursing. are still formulating ways to better enhance their curriculum with learning through simulation. Additionally, the cost of high-fidelity simulation equipment is a drawback; it was recommended that schools organize and develop nursing simulation centers to meet regional needs. The results from this survey were limited, and there was no representation from Latin American schools of nursing. Most recently the National League for Nursing has embarked on the development of a Simulation Innovation and Resource Center (Hovancsek et al., 2009), which is a collaborative effort of nurse educators from abroad to include countries as far away as Chile. As a result of the initiative, the National League for Nursing has developed online learning modules on the use of simulation for faculty to access globally. As simulation becomes more widespread, there is a burgeoning need to formalize and share perspectives. The Simulation Innovation and Resource Center acts as a center for simulation scenarios and interactive activities that can be shared with international educators. This grant was sponsored by Laerdal Medical Corporation, the maker of the patient simulator SimManÒ. To date the only Latin American country involved in this collaborative is Chile. While this is a promising start, there needs to be better representation from Latin American institutions in the collaborative. In light of these findings, opportunities abound for collaboration with our Latin American nursing colleagues. Development of regional simulation centers may meet the need of nursing schools in this time of restricted resources.
Global Initiatives at USF USF, as part of its global initiative, has a working relationship with the country of Panama. For approximately 5 years, USF undergraduate nursing students have had the opportunity to travel to Panama as part of the community health elective. Students are immersed in the Panamanian
culture by being paired with host students, living with families, and participating in the daily activities of the Panamanian people. On arrival in Panama, students are assigned to rural clinical sites that are typically several hours away from the capital. Overall clinical experiences vary but include well-woman checkups, healthy children visits, births, vaccinations, and the development of educational initiatives in consultation with local nurses. USF nursing students pay to participate in this clinical experience. The fees cover airfare, room, and living expenses. In addition, students register for a 4-credit clinical course; nursing students at USF are required to earn 124 credit hours in order to graduate with a baccalaureate in nursing. A faculty member travels with the students and oversees the clinical requirements.
Breaking Barriers to Simulation in Pan-America: A University Initiative As a consequence of this well-established relationship, in the fall of 2009 USF faculty cohosted with the University of Panama the first preconference workshop on simulation, titled Integration of Simulation Across a Nursing Curriculum. The nursing conference, La Asociacio´n Latino Americano de Educacio´n en Enfermerı´a, is an annual nursing conference attended by hundreds of Latin American nurses from as far away as Chile and Peru. The purpose of this article is to detail one USF faculty member’s experience of hosting a simulation workshop in Panama and to illustrate the need to assist our Latin American colleagues in the adoption of simulation as a teaching strategy. As cohosts of the preconference, faculty members were asked to develop a preconference workshop for participants. It was decided that the workshop would consist of two half-day workshops with both a didactic and a handson component. The content and all the materials were developed in Spanish. Registration was handled through the office of continuing professional education at USF. The cost for the workshop was US$20 per delegate and covered snacks and materials. Faculty travel and attendance were paid for by a small internal grant through the office of International Studies of Latin American Countries. The conference was held at the University of Panama, located in the city of Panama. The University of Panama is the public university for the country and has one of Panama’s nursing programs. The simulation preconference workshop was held at Universidad Latina, which is a private school of medicine and nursing in the city of Panama. It has a well-equipped simulation laboratory, which is used predominantly by the physicians and medical students. The laboratories have a SimManÒ (Laerdal), NOELLEÒ (Gaumard), several VitalSimsÔ (Laerdal), and live streaming video and audio capability. There are two full-time staff members responsible for the development and integration of simulated experiences. Marketing and advertisement of
pp e177-e180 Clinical Simulation in Nursing Volume 8 Issue 5
Simulation Workshop
e179
the workshop were handled by the Universidad Latina in conjunction with the University of Panama. Materials for the workshop were developed with the National League for Nursing’s Simulation in Nursing Education: From Conceptualization to Evaluation (Jeffries, 2007) as a template. It was supplemented by the presenters’ personal experience and expertise in simulation. All materials were provided to attendees at the beginning of the workshop both as paper handouts and in an electronic format in the form of a hyperlink. Thirty participants registered and attended the workshop. Most attendees spoke no English. Attendees were either nursing faculty or staff nurses, in most instances both there was one physician in attendance. There was a tremendous sense of camaraderie; all attendees were engaged and asked thoughtful questions during the didactic portion. After the didactic session, participants were asked to move into the laboratory, where the simulated experiences occurred. Prior to the simulation, all participants were oriented to the simulator’s features. The format used was an unfolding case scenario, with a primary nurse caring for the patient and the other attendees observing and critiquing. Time was allotted for questions, answers, and debriefing. Very few of the participants had any previous experience with this type of simulation. Participants had differing perspectives in relation to simulation; many of the participants did not realize how powerful simulation as a teaching strategy could be. Some indicated that they wished this technology had been available when they were students. All participants recognized the value of interdisciplinary simulation as a way to improve communication among physicians, nurses, and members of the health care team. However, when queried about the potential for future workshops, most described lack of resources as a barrier to continuing education. Participants were quick to point out how much they appreciated the workshop being presented in their native language. It is not uncommon to find English-speaking presenters at foreign conferences, and at times the attendees may feel resentful that an effort was not made to present in their native language. Speaking Spanish afforded the presenter the opportunity to quickly build rapport with the attendees. Issues that should be considered for future events include the perception of time. Latinos often have a different perception of time orientation (Marin & VanOss-Marin, 1991). Both sessions started very late because attendees did not arrive at the expected time. Attendees typically showed up 30 minutes late to the session. This created an issue for the presenter. When queried about reasons for being tardy, most participants mentioned the long distances they drove in order to attend the workshop, 5 hours in some instances. Another issue was the perception that simulation was used only to teach psychomotor skills such as catheter insertion and wound care management, as opposed to case development and critical thinking application, which is common with the use of high-fidelity simulation in the United States.
Expensive simulators are not necessary to run highly realistic scenarios. In fact, with some creativity, a mid-fidelity simulator and task trainer work as well. At the Universidad Latina, simulation is used predominantly with medical students with medical students, while nursing students use simulation as an opportunity for skill attainment. The idea of developing scenarios for teaching was novel and not a strategy faculty members were particularly familiar with. For many of the participants, the use of simulation in their curriculum or as part of staff development will never be realized as very little is available for the purchase of such expensive equipment. Likewise, grants and endowments are lacking among the Pan-American institutions. One of the major distributors of the patient simulators does not have representation in Pan-America as interest and ability to purchase such expensive equipment is limited. Ongoing discussion is needed to assist our colleagues in finding available funding sources and potential partnerships with universities in the United States.
Conclusion The attendees of the preconference workshop were excited and enthusiastic about simulation. Nursing faculty in PanAmerican schools of nursing are just now recognizing the power of simulation as a teaching strategy. However, limited resources and funding have prevented the acquisition of patient simulators for most programs. Patriarchal sentiment and geography are just a few of the barriers to implementing simulation in nursing curricula. The PanAmerican countries would do well to develop a consortium and pool funding sources to create multiprofessional simulation centers that serve geographical areas rather than individual schools of nursing. One idea worth considering is donation of older simulators to a PanAmerican nursing program. In light of current financial constraints, Pan-American countries are unable to provide monetary support or stipends to have experts in simulation present locally. Creative ways are needed to generate funding to sponsor experts in the field of simulation. One way would be to require all the participating universities and health care organizations to pay a small fee for using the multiprofessional simulation centers. A portion of the fees could be used to secure experts in the field of simulation. If we consider local health to be as important as global health, then nursing educators in Pan-America could use the support to bring simulation technology to their institutions in order to enhance teaching strategies and ultimately graduate better prepared nurses.
References Hovancsek, M., Jeffries, P., Escudero, E., Foulds, B. J., Husebo, S. E., Iwamoto, Y., et al. (2009). Creating simulation communities of practice: An international perspective. Nursing Education Perspectives, 30(2), 121-125.
pp e177-e180 Clinical Simulation in Nursing Volume 8 Issue 5
Simulation Workshop
e180
Institute of Medicine. (2004). Keeping patients safe: Transforming the work environment. Washington, DC: National Academies Press. Jeffries, P. (Ed.). (2007). Simulation in nursing education. New York: National League for Nursing. Marin, G., & VanOss-Marin, B. (1991). Research with Hispanic populations (Vol. 33). Newbury Park, CA: Sage. Metcalfe, S. E., Hall, V. P., & Carpenter, A. (2007). Promoting collaboration in nursing education: The development of a regional simulation laboratory. Journal of Professional Nursing, 23(3), 180-183.
Nehring, F. R., & Lashley, W. M. (2004). Current use and opinions regarding human patient simulators in nursing education: An international survey. Nursing Education Perspectives, 25(5), 244-248. Rauen, C. (2001). Using simulation to teach critical thinking skills: You cannot just throw the book at them. Critical Care Nursing Clinic North America, 13, 93-103. Touriniemi, P., & Schott-Baer, D. (2008). Implementing a high-fidelity simulation program in a community college setting. Nursing Education Perspectives, 29(2), 105-109.
pp e177-e180 Clinical Simulation in Nursing Volume 8 Issue 5