Integrated Literature Review
The purpose of this integrated literature review is to report the published works on high fidelity simulation in nursing education, looking specifically at presenting the advantages and disadvantages of replacing hospital clinical hours with high fidelity simulation. The National Council of State Boards of Nursing simulation study reported that up to 50% of clinical time in simulation can provide the same clinical performance as traditional clinical placements yet concerns remain about the ability for simulation to replace traditional clinical placements (Harder, 2015). This paper will discuss how increased use of high-fidelity simulation in nursing education has affected clinical experiences for nursing students, educators and the profession. High fidelity simulation will be defined, and the effects on substitution for clinical hours within nursing programs will be discussed.
The Role of Simulation in Nursing Education
The knowledge base and expectations of student nurses entering the profession has increased tremendously over the past decade to meet the demands of expanding roles of the Registered Nurse. As technology advances in healthcare, nurse educators struggle to keep the pace (Alt-German, 2019). Educators have the responsibility of meeting demanding educational needs, while dealing with challenges of faculty shortages, increased numbers of enrolled students and too few clinical placement sites (Larue, Pepin, & Allard, 2015). Simulation in nursing education has been used for many decades to improve skills, confidence and critical thinking however, technology improvements have taken this type of learning to a new level (Harder, 2015). It is essential that educators meet theses challenges and prepare students to meet the demands of entry level graduate expectations by providing experiences that link education to practice; evidence shows this can be achieved using real-life clinical experiences such as high fidelity simulation (Mauro, Dawn, Tracey, LoGrippo, Anderson, Bravo.. Escallier. 2018). The National Council for State Boards of Nursing Simulation Study determined that simulation could be substituted for traditional clinical hours with equivocal education outcomes in prelicensure nursing programs (Breymier, Rutherford-Hemming, Horsley, Smith, & Connor, 2015). Harder (2015), suggests focusing on “why” replacing clinical experiences with simulation benefits students and thinks current practice models used in many nursing programs is considered outdated while literature supporting new evidence for clinical practice models is limited.
Defining High Fidelity Simulation
High Fidelity simulation can be defined as “Experiences using full scale computerized patient simulators, virtual reality or standardized patients that are extremely realistic and provide a high level of interactivity and realism for the learner” (Larue, Pepin, & Allard, 2015). It was also defined by Breymier, Rutherford-Hemming, Horsley, Smith, and Connor, (2015) as “supervised clinical experiences while providing students similar opportunities to demonstrate procedures, participate in decision-making, utilize critical thinking, and communicate with each other in a nonthreatening, standardized environment.” Researchers have identified high-fidelity simulation as an alternative clinical experience to enhance student development while in a safe atmosphere for both the student and patient (Headstream-Pehl, & Kunce-Collins, 2017). While many variations of the definition of high-fidelity simulation were discovered, it can be concluded that this type of learning allow for students to develop skills through realistic clinical experiences in a safe environment.
Studies on knowledge outcomes within students when high-fidelity simulation was used instead of traditional simulation varies. Throughout the review, common categories identified with this method of teaching/learning demonstrated repetitive themes about self-confidence, critical thinking and safety. According to Curl, Smith, Chisholm, McGee, and Das (2016), high-fidelity simulation can be used to increase capacity beyond traditional clinical space because it facilitates cognitive abilities a knowledge in a safe environment.
Headstream-Pehl and Kunce-Collins, (2017) added to the simulation debate after completing a study investigating the premise if simulation experiences are comparable in effectiveness to hospital clinicals for nursing students at Tarleton State University. Their study used a 3-group, double blind method for group assignment, with a sample size of sixty participants. The study design used pre-test/post-test scores and semester exam scores after a four-week clinical rotation of three separate clinical experiences. All three rotation groups completed all three clinical experiences during the 2012 fall semester. Each rotation group attended four weeks of clinical instruction in the hospital with a clinical instructor, in the hospital with a preceptor and in the simulation lab with a clinical instructor. The results showed no difference in scores between the test and control groups, thus supporting the literature review and the null hypothesis. Conclusions of the study report an equivocal valuable learning experience for nursing students and support the use of simulation as a teaching methodology. Perceived benefits were reflected in the students debriefing journals. Neither educators nor students endorsed the replacement of clinical patient care with simulation but the combination of the two should potentiate the learning effect. Limitations of this study were sample size, technical difficulties that occurred during the simulation in one group.
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Curl, Smith, Chisholm, McGee, and Das (2016), also contributed to the research on simulation with the research study that focused on the evaluation of effectiveness of using high-fidelity simulations to replace fifty percent of traditional clinical experiences for nursing students. This quasi-experimental research design was used to test whether students that participated in high-fidelity simulation and clinical experiences would attain more than those solely enrolled in traditional clinical experience programs. The study had a control group and study group that were made up of volunteer nursing students from one of three schools for a total of 124 participants. The results showed a comparison between the groups, study versus control with the focus of high-fidelity simulation instruction specialty exams and exit exam which were compared to NCLEX-RN questions. The conclusions were in favor of high-fidelity simulation replacing traditional clinical hours with one hour in simulation as equivalent to two hours of traditional clinical.
Advantages of High-Fidelity Simulation
High fidelity simulation is rapidly spreading in the world of nursing education. Many of the published studies show very positive outcomes in favor of this learning style and are in favor of restructuring programs to include simulation as part of the clinical program (Larue, Pepin, & Allard, 2015). Consistent reports found within the articles report realistic clinical opportunities that may not have occurred in traditional clinical settings, safe learning environment, and the promotion of confidence of students. There is substantial evidence that high-fidelity simulation provides realistic clinical opportunities that promote confidence and preparedness for practice of students (Mauro, Dawn, Tracey, LoGrippo, Anderson, Bravo, ..Escallier. 2018). High Fidelity simulation offers a safe alternative to allow students to expand their knowledge and abilities without putting patients or students at risk (Headstream-Pehl & Kunce-Collins, 2017). According to Larue, Pepin and Allard (2015), simulation reinforces self-confidence and facilitates learning and the capacity of students to mobilize their resources in clinical settings. Students need to play an active role in their learning, so they are empowered and motivated to learn. This type of learning provides students with the opportunity to practice rare situation that may not occur during traditional clinical rotations which help instill confidence and enhances critical thinking. Students can be active and in control of their learning which is part of the student- centered learning approach to learning (Curl, Smith, Chisholm, McGee, & Das, 2016).
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Much of the evidence favors this learning model as it clearly benefits the student, there is also benefit to other areas of the profession. High-fidelity simulation frees up clinical placement spaces allowing for higher quality traditional clinical placement since schools will not have to compete for limited space (Harder, 2015). This will ease workload of nurse supervisors and clinical preceptors and allow them to be more productive when precepting. Decreasing the need to find clinical placement each semester also eases the financial burden of human resources required to manage clinical placements (Curl, Smith, Chisholm, McGee, & Das, 2016).
Disadvantages of High-Fidelity Simulation
Although much of the literature shows positive reviews for high-fidelity simulation, it is not without shortcomings. Upon review, one of the biggest disadvantages is the price. Simulation centers are expensive and can cost upward of $200,000 to $1.6 million dollars in startup costs and at least $15,000 for annual maintenance (Herrington, 2017). They are high maintenance in terms of upkeep for any institution in terms of material and human since training of educators is needed. Reviews reveal that the instructors are not properly trained nor competent in debriefing of simulation; which is considered the most valuable part of the learning experience (Breymier, Rutherford-Hemming, Horsley, Smith, & Connor, 2015). Being a simulation educator is different from being an actual healthcare provider and educators need to update themselves on the latest simulation technologies. According to Larue, Pepin, and Allard (2015), simulation learning has limitations since resources related to the development of professional socialization and communication occur mainly through clinical experiences. Students may lose site of reality and simulation and not be comfortable around people since the experiences are not “real” . Simulation can only provide a limited amount of preparedness which can be forgotten when dealing with human lives. This can cause unnecessary stress for some students and interferes with learning (Curl, Smith, Chisholm, McGee, & Das, 2016).
Relation to Nursing Education
The role of high-fidelity simulation has great effect on nursing education and much of the reviews indicated that nursing programs are using a high percentage of high-fidelity simulation models (Curl, Smith, Chisholm, McGee, & Das, 2016). While the studies presented most often use simulation to substitute clinical hours, this type of simulation uses behavioral or constructivist approaches. In the behavioral approach, understanding an action is the priority, whereas a constructivist approach requires understanding and mobilization of multiple resources. This follows hierarchical learning theory which can be used to measure performance.
The simulation learning theory evaluates students and provides opportunities for expression of feelings which uses all the domain of learning.
This integrated literature review has discussed the published works published works on high fidelity simulation in nursing education, looking specifically at presenting the advantages and disadvantages of replacing hospital clinical hours with high fidelity simulation. Issues within nursing programs clinical experiences caused a need to identify new ways to improve education for student nurses. High-fidelity simulation has been extensively researched over the past several years and now demonstrates mounting evidence on the ability to improve performance including skills, knowledge base, increased confidence and critical thinking (Harder, 2015).
- Breymier, T., Rutherford-Hemming, T., Horsely, T., Smith, L., & Connor, K. (2015). Substitution of clinical experience with simulation in prelicensure nursing programs: A national survey in the United States. Clinical Simulation in Nursing, 11(11), 472-478. doi: org/10.1016/j.ecns.2015.09.004
- Curl, E., Smith, S., Chisholm, A., McGee, L., & Das, D. (2016). Effectiveness of integrated simulation and clinical experiences compared to traditional clinical experiences for nursing students. Nursing Education Perspectives, 37(2), 72-77. Received form https://www.ncbi.nlm.nih.gov/pubmed/27209864
- Harder, N. (2015). Replace is not a four letter word. Clinical Simulation in Nursing, 11, 435-436. Retrieved from https://www.nursingsimulation.org/article/S1876-1399(15)00057-2/abstract
- Headstream-Pehl, S., & Kunce-Collins, D. (2017). Validating the use of high-fidelity simulation as a clinical adjunct in undergraduate nursing education. Journal of Healthcare Communications, 2(3). doi: 10.4172/2472-1654.100064. Retrieved from http://healthcare-communications.imedpub.com/validating-the-use-of-highfidelity-simulation-as-a-clinical-adjunct-in-undergraduate-nursing-education.php?aid=19279
- Herrington, A. (2017). Simulation center finances: calculating fees and costs. Retrieved from http://nursingeducation.lww.com/blog.entry.html/2017/10/30/simulation_centerfi-UWPs.html
- King, D., Tee, S., Falconer, L., Angell, C., Holley, D., & Mills, A. (2018). Virtual health education: Scaling practice to transform student learning: Using virtual reality learning environments in healthcare education to bridge the theory/practice gap and improve patient safety. Nurse Education Today, 71, 7-9. doi.org/10.1016/j.nedt.2018.08.002
- Mauro, A., Tracey, D., LoGrippo, M., Anderson, S., Bravo, A., Geissler, B.. Escallier, L. (2018). Simulation innovation to redesign the baccalaureate curriculum to address population health. Nurse Educator, 43(5), 232-237. doi: 10.1097/NNE.0000000000000520
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