Creating Clinical/Simulated Learning Experiences

Choose one of the clinical learning situations below and suggest ways to create a successful learning experience. Also comment on how the topic could be applied in other settings (academic and online). Refer to Teaching in Nursing: A Guide for Faculty (Chapters 17 and 18), New Technologies in Nursing Education, and A Vision for the Changing Faculty Role: Preparing Students for the Technological World of Health Care to support your suggestions.

The clinical learning situations are as follows:

  • A high-fidelity simulation addressing care of a patient with congestive heart failure
  • A six-hour clinical rotation addressing patient care given on a telemetry unit
  • A low-fidelity simulation addressing the psychosocial care of a suicidal patient
  • \

Chapter 18

Teaching and Learning Using Simulations*


Pamela R. Jeffries, PhD, MSN, RN, FAAN, ANEF;

Sandra M. Swoboda, RN, MS, FCCM;

Bimbola Akintade, PhD, MBA, MHA, ACNP-BC, CCRN


The complexities of the health care system coupled with a changing patient population have created a need for nursing students to be prepared to care for all types of patients in a variety of care settings. Additionally, as health care shifts to community settings, nurse educators have been challenged to find appropriate clinical sites and clinical experiences for nursing students to meet curricula competencies and required clinical experiences. Because of these challenges, nurse educators are exploring alternative strategies for clinical preparation for nursing students. Simulation offers nurses, students, and health professionals the opportunity to learn in situations that are comparable to actual patient encounters within a controlled learning environment (Alden & Durham, 2012; Katz, Peifer, & Armstrong, 2010) that supports the learners’ transfer of classroom and skills laboratory knowledge to realistic patient interactions (Anderson & Warren, 2011; Halstead, 2006; Meyer, Connors, Hou, & Gajewski, 2011). Clinical simulation technology is becoming increasingly more realistic, and nursing programs are making substantial investments in equipment and learning space. As simulations and related teaching and learning strategies move into nursing programs, and evidence supports clinical simulations as an alternative to actual clinical experiences (Hayden, Smiley, Alexander, Kardong-Edgren, & Jeffries, 2014), nurse educators must be prepared to teach using this methodology.

This chapter discusses simulations as an experiential, student-centered pedagogical approach. The chapter begins with an overview of types of simulation—the purposes, challenges, and benefits of clinical simulations—and concludes with information about planning, implementing, and evaluating simulations as they are integrated into courses and curricula. The chapter emphasizes (1) the types of clinical simulations being developed and implemented in nursing programs; (2) challenges and benefits to student learning, thinking, and practice; (3) a framework and steps to consider when developing and using clinical simulations; and (4) the evaluation component to consider when implementing simulations in the teaching–learning environment.



Simulations are activities or events, such as performing basic life support on a patient simulator to manage a cardiac arrest, that mimic real-world practice. Simulations are used when real-world training is too expensive, occurs rarely, or puts participants (or patients) at unnecessary risk. Simulations provide the opportunity for students to practice within their scope of practice, think critically, problem solve, use clinical reasoning, and care for diverse patients in a nonthreatening, safe environment. Incorporating simulations into a nursing curriculum as a teaching and learning strategy offers nurse educators the opportunity to support learners’ educational needs by providing them with an interactive, practice-based instructional strategy.


Simulation Nomenclature

There are various types of simulations. The terms used to describe various aspects of the simulation experience are described here. The simulation nomenclature matrix includes learning domains and tool and environmental realism. Tool and environmental realism are further categorized into types of 305fidelity—low, medium, and high—and the context of the fidelity as partial or full.



Fidelity, or the realism of simulations, is described along a continuum—from low fidelity to high fidelity—relative to the degree to which they approach reality.

• Low fidelity: This type of simulation experience includes case studies to educate students about patient situations, role playing, the use of a partial task trainer or static manikin (e.g., plastic model arm to learn how to perform a venipuncture, wound care trainer for wound management) to allow students to perform a task or skill. Low-level realism is present; however, principles and concepts can still be learned using this type of simulation (International Nursing Association for Clinical Simulation and Learning [INACSL] Board of Directors, 2011).

• Medium fidelity: This type of simulation is technologically sophisticated in that the participants can rely on a two-dimensional, focused experience to solve problems, perform skills, and make decisions during the clinical scenario. These manikins have the ability to auscultate heart sounds and breath sounds but the chest does not rise. Some examples include VitalSim Anne and VitalSim Kelly.

• High fidelity: This type of simulation involves full-scale, high-fidelity human patient simulators, virtual reality or standardized patients (actress or actors portraying simulated patients that have certain health disruptions) that are extremely realistic and provide a high level of interactivity and realism for the learner (International Nursing Association for Clinical Simulation and Learning [INACSL] Board of Directors, 2011). Examples include SimMan 3G, SimNewbie, iStan, and METI HPS, as well as a birthing simulator called Victoria and her newborn infant, all of which permit the student to listen to various body sounds and can be programmed to talk and to respond to interventions performed by the students.



Partial or Full-Context Simulations

The context of simulations can be partial or full.

• Partial task trainers: Partial task trainers are those simulations in which a body part, plastic model, or partial manikin is used to depict a certain function and on which a student can practice a particular psychomotor skill. Examples of partial task trainers include intravenous (IV) cannulation arms and low-technology manikins that are used to help students practice specific psychomotor skills integral to patient care such as inserting urinary catheters or nasogastric tubes.

• Full-context simulations: These simulations include the full context of a scenario, an event, or an activity that replicates reality. For example, a static manikin with limited functions such as VitalSim Kelly is full context but medium fidelity. The full context of an event can be represented using this type of simulation in a low-fidelity manner. High fidelity, full context is a simulated learning experience using a high-fidelity simulator and immersing the participants in a realistic mock code situation or a simulated live birth.

Full-scale patient simulations using sophisticated, high-fidelity patient simulators provide a high level of interactivity and realism for the learner. Less sophisticated, but still educationally useful, are computer-based simulations in which the participant relies on a two-dimensional, focused experience to solve problems, perform skills, and make decisions during the clinical scenario. Studies have shown that the two-dimensional experience has merit in terms of positive learning outcomes and skill acquisition (Jeffries, Woolf, & Linde, 2003). Partial task training devices such as IV arms and haptic (force feedback) IV trainers are used in simulations for psychomotor skills. The learner is able to practice a skill repeatedly before performing it on a real patient. The partial task trainers typically ensure a satisfactory rate of achievement of objectives and benefit to the participant. Studies have shown that after having used these task trainers, participants demonstrate a psychomotor skill and use that skill set in the real patient environment (Engum & Jeffries, 2003). Programs or courses in which the task trainers are used include clinical laboratory courses and modules during which specific skill sets and goals need to be obtained. Another approach to learning is the use of two-dimensional CD-ROMs to provide interactive practice with skills.



Types of Simulation

Simulations variously involve role playing, standardized patients (actors), interactive videos built 306on gaming platforms, and manikins to teach procedures, decision making, and critical thinking in realistic environments (Ryan et al., 2010). There are a variety of technology-based simulations to support student and novice nurses. They include computer-based interactive simulations, haptic partial task trainers, and digitally enhanced manikins. Haptic trainers use force feedback to provide opportunities to develop psychomotor skills. In addition to types of simulations categorized by the equipment or manikin used, there are simulations categorized by the type of pedagogy used when implementing the simulations. These types of simulations are described in the following sections.


Hybrid Simulations

A hybrid simulation is the combination of a standardized patient and the use of a patient simulator in one scenario to depict a clinical event for the learner. For example, the simulation scenario may begin with the student performing a health history on a standardized patient who has just arrived in the emergency department after having been involved in a motor vehicle accident. As the case evolves, the activity shifts to a patient simulator because of the clinical symptoms that need to be demonstrated by the manikin to reflect reality. This is a hybrid simulation because the history is being performed on a standardized patient and then the scenario shifts to a patient simulator, where the patient is now experiencing “hypovolemic shock” that is being reflected in the vital signs and other clinical findings of the manikin. A common hybrid simulation in obstetrics involves a low-fidelity task trainer with a standardized patient for simulations of normal birth or complications such as shoulder dystocia. This can be done with a standard actor and the pelvis of a birthing simulator or with the use of the Mama Natalie, which is a low-cost, wearable device that can manually deliver a baby and placenta and simulate postpartum complications.



Unfolding Case Simulations

Another type of simulation is the unfolding case. Unfolding cases evolve over time in an unpredictable manner. An unfolding case may include three to four events that build on each other, providing students an opportunity to plan care across a clinical event, a hospitalization, a care transition or across the life span (Page, Kowlowitz, & Alden, 2010). Unfolding cases can be used to meet a variety of learning goals:


1. To demonstrate hierarchal order so the learner can follow the progression of a health problem and the related nursing care. For example, the first scenario demonstrates the patient being admitted with a head injury caused by a fall; the learner must conduct a focused neurologic assessment. The unfolding case leads to a second scenario, in which the patient experiences specific neurologic signs (e.g., severe headache, widening pulse pressure); the learner must use additional assessment skills. The third case occurs postcraniotomy and involves care of the patient after the subdural hematoma is removed.

2. To visualize and prioritize hospital trajectory and care of a patient that progresses. For example, the patient is admitted through the emergency department, with the learner performing an assessment. The second scenario depicts the patient being admitted to the progressive care unit and the third scenario is designed for the learner to prepare the patient with discharge instructions.

3. To provide the learner with a view of care transitions, showing the effect of the health disruption or disease process and nursing interventions required for a particular patient. For example, the first scenario depicts a hospitalized patient newly diagnosed with chronic obstructive pulmonary disease (COPD). The second scenario progresses to the patient having compromised gas exchange related to COPD and being managed at an ambulatory care center. The third scenario depicts end-stage disease with a focus on end-of-life care with hospice care.

4. To serve as a mechanism to include a variety of important assessments and findings where one event leads to another. For example, the first scenario focuses on hypotension and subtle findings of sepsis and the second scenario centers on the critically ill patient with sepsis and hypotension.

Several organizations have developed unfolding case studies related to particular topics that are available at no cost to faculty. Four unfolding cases 307that focus on older adults and address the complexity of decision making about their care can be found at; unfolding cases related to patient safety can be found at the Quality and Safety Education for Nurses (QSEN) site at



Standardized Patients

Standardized patients are live actors trained to portray the role of a patient according to a script or clinical scenarios written by the faculty. The actors become the patients, demonstrating clinical symptoms and responses of real patients. A variation of the standardized patient instructional strategy is the use of these types of simulations to evaluate physical assessment skills, history taking, communication techniques, patient teaching, and types of psychomotor skills or objective structured clinical examination (OSCE).



In Situ Simulations

In situ simulation is a type of simulation that involves training performed in a real-life setting where patient care is commonly provided (Dismukes, Gaba, & Howard, 2006). The aim of this type of simulation is to achieve high fidelity (realism) by performing the simulations in actual clinical settings, blending and providing both a clinical and learning environment. Typically, the simulation-based experiential learning focuses on interdisciplinary professional teams. Practicing professionals are well versed in their particular field, possess a fair amount of experience, and prefer their learning to be problem-centered and meaningful to their professional lives. Adults learn best when they can immediately apply what they have learned. Traditional teaching methods (e.g., a teacher imparts facts to the student in a unidirectional model) are not particularly effective in adult learning because it is important for adults to make sense of what they experience or observe.



Virtual Simulations and Digital Platforms

Simulations can also take place in virtual environments. Increasing development in virtual patient simulation is evolving and allows the learner to interact with the patient and the virtual environment where the patient is responsive to interventions through a digital media platform. An example of this platform is Second Life, a virtual world accessible by the Internet that enables its users to interact with each other through avatars. In this simulated world, users can explore, meet other users, socialize, participate in individual or group activities, and create services for one another or travel throughout the world. The software is a three-dimensional modeling tool that attempts to depict reality for the users. Second Life is used as a platform for education by many institutions, such as colleges, universities, libraries, and government entities. For the top 10 health care–related virtual reality applications, go to

There are other platforms whereby software programs replicate clinical practice and respond to learner interactions; some provide written feedback to the learner with suggestions and evidence as feedback. Simulation through game-based learning can be independently performed or moderated and this type of simulation helps prepare students for the clinical setting and allows the learner to make decisions and interact with a patient with real-time response in a safe learning environment.

Cook (2012) designed and evaluated a virtual world simulation for family nurse practitioner students and also created a primary care pediatric simulation for use by family nurse practitioner students in Second Life. Seefeldt et al. (2012) used Second Life to allow pharmacy, nursing, physical therapy, occupational therapy, and physician assistant students to interact around a mock patient case. The pilot study examined the feasibility of using Second Life as a means to foster interprofessional education (IPE). Students overall found the platform useful; however, there were technical difficulties in using the platform and students lacked the necessary knowledge and skills to use the platform. Farra, Miller, Timm, and Schafer (2013) found out that virtual environments can be used as a learning strategy for nursing students to practice and hone their disaster response and management skills. The study found that students were able to retain the knowledge after the simulation and there was an overall positive response to the use of the virtual platform.



Purpose of Simulations

Clinical simulations in nursing education can be used for many purposes, for example, as a teaching strategy or for assessment and evaluation, or as an avenue to encourage IPE. However, one of the most important reasons that educators use simulations 308is to provide experiential learning for the student. Students can be immersed in a simulation where they can actually portray the primary nurse, a newly employed nurse in orientation, or whatever role within the scope of nursing practice the learner is assigned.


Simulations as Experiential Learning

The use of simulation corresponds with a shift from an emphasis on teaching to an emphasis on learning (Dunn, 2004; Jeffries, 2005) in which the faculty facilitate learning by encouraging students to discover, or construct, knowledge and meaning. Kolb (1984) and others (Sewchuck, 2005; Svinicki & Dixon, 1987) suggest that the experiential learning cycle is a continuous process in which knowledge is created by transforming experience. Individuals have a concrete experience, they reflect on that experience (reflective observation), they derive meaning (abstract conceptualization) from the experience, and they try out or apply (active experimentation) the meaning they’ve created, thus continuing the cycle with another concrete experience.

When making a shift in approach from a focus on teaching to a focus on learning, goals of the educational programs serve as the framework for the development of specific learning activities. For example, both nursing students and novice nurses entering professional practice find it difficult to transfer theoretical knowledge into clinical practice. The use of simulation allows students to experience the application of theory in a safe environment where mistakes can be made without risk to patients.

The use of highly realistic and complex simulation may not always be an appropriate educational approach. In some situations, beginning students can use low-fidelity simulation to work on attainment of foundational skills, including effective communication with patients, psychomotor skill performance, and basic assessment techniques. With task trainers or standard manikins, students can practice procedural skills and caregiving in a safe environment that allows them to make mistakes, learn from those mistakes, and develop confidence in their ability to approach and communicate with patients in the clinical setting. In addition, students benefit from the opportunity to work with technologically sophisticated equipment such as clinical information systems and hemodynamic monitoring systems in the educational setting before encountering such equipment in the clinical setting.

Advanced practice nursing students benefit from high-fidelity simulations that are complex, realistic, and interactively challenging experiences that support them in developing and practicing leadership abilities, teamwork, and decision-making skills. With patient simulators, for example, students can practice complex assessment skills in their area of clinical practice. Faculty can create scenarios and program equipment to simulate serious clinical situations such as respiratory arrest or aberrant cardiac rhythms that may require an emergent response. Simulations are also appropriate to prepare psychiatric nurse practitioners. As students respond to these more complex situations, they demonstrate their abilities to establish priorities, make decisions, take appropriate action, and work successfully as part of a team (Reese, Jeffries, & Engum, 2010). Within the simulated environment, advanced students also can demonstrate application of learning because they are no longer merely acquiring knowledge and skills. Students learn from the simulated practice without the need for faculty stepping in to correct and control the situation. High-fidelity simulation affords all students the opportunity to experience a baseline set of clinical scenarios, including those that are uncommon or rare, and to practice skill sets repeatedly until they develop a routine and process for safe patient care (Reising & Hensel, 2014).



Simulations as a Teaching–Learning Strategy

Nurse educators have used low-fidelity simulation such as manikins, role play, and case studies as a teaching–learning strategy for decades. The introduction of high-fidelity simulation (in the form of affordable, portable, and versatile human patient simulators) in the late 1990s transformed health care education and is now one of the foundational strategies in the preparation of health care professionals not only for teaching, but also for assessment and evaluation, developing interprofessional team skills, and for clinical substitution and make up for missed experiences.



Simulations Used for Assessment and Evaluation of Learning

Given the widespread use of simulations, there is also the potential for using simulations for assessment and evaluation of student learning. Using simulation 309for assessment and evaluation of learning should be integrated into the larger process of planning, implementing, assessing, and evaluating learning. Faculty should identify the purpose of the assessment or evaluation early in the process to ensure the evaluation is relevant and evaluates the learning outcomes for which it is intended (Adamson, 2014). Although more traditional forms of assessment continue to be employed—for example, pretesting and posttesting using multiple-choice tests—simulation-based assessments are increasingly being used in the evaluation process, both in a formative manner, as part of an educational activity or training, or in a summative manner, as part of a graduation or certification process.

When simulations are being used for assessment or evaluation, the activities fall into two broad categories—“low-stakes” and “high-stakes” situations—depending on the significance of the evaluation (Boulet & Swanson, 2004). Low-stakes assessments are situations in which the simulation is used by the learner and faculty to mark progress toward personal, course, or program learning goals. High-stakes assessments include licensing and certification examinations, credentialing processes, and employment decisions (Jeffries, Hovancsek, & Clochesy, 2005). Simulation technologies used for assessment range from case studies and standardized patients (e.g., OSCEs) to haptic task trainers and high-fidelity human simulators.

As with any type of assessment, faculty must consider the issues of validity and reliability. For assessments in low-stakes or learning situations, construct and concurrent validity should be addressed. Construct validity is the degree to which an assessment instrument measures the dimensions of knowledge or skill development intended. Concurrent validity is determined by evaluating the relationship between how individuals perform on the new assessment (in this case a simulation) and the traditional (standard) assessment instrument. An assessment with high concurrent validity, for example, is one in which the learner’s simulator assessment score is comparable to his or her score when performing the same examination on a standardized patient scored by using a checklist.

Predictive validity is required for simulations used in assessments in which licensure, certification, or employment are at stake. Determining predictive validity in high-stakes assessment is a complex process. Predictive validity is the extent to which performance on a particular simulation predicts future performance, such as clinical decision making or psychomotor skills. Evaluating predictive validity requires that, in addition to current performance, the clinical skill or decision making of specific individuals be tracked over time. There has been little research and evidence-based information specifically focused on quantifying the effect of simulation-based assessment activities on student or practitioner learning.

Simulations also are being used to assess and evaluate students’ clinical skill competencies and clinical decision-making capabilities. Using standardized patients to assess the clinical skills of medical students and residents has become widespread (Chambers, Boulet, & Gary, 2000). OSCEs are clinical examinations that vary in format but mostly include a set period for the student to assess and interact with a standardized patient, an actor or actress hired to portray a certain type of patient with a specific diagnosis and clinical symptoms. Wilson, Shepherd, and Pitzner (2005) used the low-fidelity human patient simulator to acquire and then assess nurses’ health assessment knowledge and skills. The use of the low-fidelity manikins proved to be an effective tool to assess for health assessment skills. Miller, Leadingham, and Vance (2010) used the human patient simulator to meet learning objectives across core nursing courses.

When using simulations as an assessment mechanism, the nurse educator should also consider the improvement in the use of standardized patients, the sophistication of computer-based evaluation techniques, the use of newer physiologic electromechanical manikins, and the fidelity of immersive haptic devices. Because of these advances, nurse educators are now better able to assess learning, promote a better educational effort, improve academic courses and programs, and ultimately prepare students to provide quality, competent and safe patient care.



Simulations Used in Interprofessional Education

Conventionally, nursing and other health care education as a whole is delivered on a uniprofessional basis, eliminating the reality of everyday interprofessional collaborative clinical practice. IPE is bridging that gap (Alinier, Harwood, & Harwood, 2014). IPE can be defined as two or more professions that work together and learn from and about one another in an effort to improve collaborative 310practices and the overall quality of patient care (Newton, Bainbridge, & Ball, 2014). (See also Chapter 11.) In Canada, IPE to improve interprofessional collaborative practice has been documented for more than 50 years, but in terms of research, it has gained popularity in the last 15 years. Currently, most health education programs are beginning to embed IPE into their curricula, thus increasing attention to continuing professional development. There are many advantages of IPE, including breaking down both real and perceived barriers between different clinical aspects, enhancing interprofessional cohesiveness and awareness, and providing an opportunity to develop mutual respect among members of an interdisciplinary team. Within an interprofessional team, an important element of providing safe and effective patient care is knowledge and understanding of other professionals’ roles and skills (MacDonald et al., 2010). A study by Alinier et al. (2014) investigated the knowledge and perceptions of immersive clinical simulation in undergraduate health care IPE. The study showed that students acquired knowledge, became familiar with other professions, and developed a better appreciation of interprofessional learning even with limited interprofessional simulation experiences. During the debriefings, discussions highlighted the importance and value of interprofessional training by students, especially when well contextualized and facilitated through exposure to realistic scenarios. Even though it is widely agreed that collaborative practice among health care professionals improves quality of care and patient outcomes, evidence-based and innovative suggestions as to how this should be accomplished are lacking. Current literature is limited in providing strategies that foster interprofessional collaborative learning in an easily adoptable and implementable way. Additional research is needed in IPE to quantify its effects on theoretical and clinical practice applications and the ability for nursing students and the integration of novice nurses into clinical practice.



Simulations Used for Clinical Substitution and Clinical Make-up

Simulations are currently being used in clinical settings to substitute for real clinical time for various reasons. For some schools of nursing, the issue of finding quality, appropriate clinical sites is a challenge for faculty, particularly in specialty areas such as pediatrics or maternal health (Hayden, Kegan, Kardong-Edgren, & Smiley, 2014; Meyer et al., 2011). Nurse educators have substituted clinical time in many cases for time in the simulation area to provide nursing students appropriate clinical experiences that are developed and implemented through clinical simulations. In some instances, schools of nursing are labeling clinical times as “off-campus” clinical for actual experiences in health care institutions and “on-campus clinical” when the clinical experience is obtained in the simulation laboratory. At New York University, adult health courses are being delivered with 50% off-campus clinical (real clinical time) and 50% on-campus clinical to help with their clinical faculty shortage and competition for clinical sites (Richardson, Goldsant, Simmons, Gilmartin, & Jeffries, 2014).

In some schools of nursing, clinical simulations are being used for “clinical make-up” days for those students missing clinical because of illness, weather, or other unforeseen causes. There can be an entire “clinical day” set up in the simulation lab for clinical hours. Some nurse educators use virtual simulations (computer-based learning) that has a debriefing component and scoring to meet clinical make-up hours when needed and when the content fits with the curriculum needs.

A landmark multisite study done by the National Council of State Boards of Nursing (NCSBN) explored the clinical competency of new graduates on their transition to practice based on their participation in either a control group, a group that substituted 25% of real clinical hours for simulations, or a group that substituted 50% of their clinical hours for simulation ( The study report stated,

substantial evidence [demonstrates] that up to 50% simulation can be effectively substituted for traditional clinical experience in all prelicensure core nursing courses under conditions that are comparable to those described in the study. These conditions include faculty members who are formally trained in simulation pedagogy, an adequate number of faculty members to support the student learners, subject matter experts who conduct theory-based debriefing, [and] equipment and supplies to create a realistic environment. (Hayden, Smiley, Alexander, Kardong, & Jeffries, 2014, p. S38)

The NCSBN also stated that the State Boards of Nursing should feel assured about the validity 311of simulation programs if nursing schools have enough dedicated staff members and resources to maintain the program in an ongoing basis. These findings are significant for the nurse educator community because too often quality clinical sites are difficult to find; health care agencies are limiting the amount of practice and procedures students can actually perform in the clinical setting; and, the client census is diminishing in the acute care settings such that clinical experiences are limited and focus only on the acute care population.



Challenges and Benefits of Using Simulations

Simulations can offer nurse educators and health care providers a significant educational method that meets the needs of today’s learners by providing them with interactive, practice-based instructional strategies. Implementing and testing the use of simulations in educational practice has both challenges and benefits.

Most of the challenges of using clinical simulations center on educators’ preparation for using simulations and interprofessional simulations. Before using simulations as a learning strategy, the faculty must have:


1. A firm foundation in experiential learning

2. Clear learning objectives for the simulation experience

3. A detailed design taking into account that an educator facilitates learning (versus tells the learner)

4. Sufficient time for learners to experience the simulation, to reflect on the experience, and to make meaning of the experience

5. Faculty development in the area of simulation pedagogy; the teaching strategy is student-centered, which for many is a paradigm shift in teaching

6. Strategic ways to quantify and document clinical simulation hours towards licensure or certification

7. When using IPE simulation, there must be alignment of student clinical placements across the professions; preparation of all faculty and preceptors involved; commitment from all professions to making IPE experiences a priority; and adequate financial, human, and space resources. (See also chapter 11)

The benefits of using simulations include:


1. Active involvement of students in their learning process. By interacting with the simulation, examples, and exercises, the learner is required to use a higher order of learning rather than simply mimicking the teacher role model. Decision-making and critical thinking skills are reinforced through this teaching modality.

2. More effective use of faculty in the teaching of clinical skills and interventions. In a simulated experience, faculty members have an opportunity to observe students more closely and to allow students to demonstrate their potential more fully. The feedback or debriefing by faculty is a powerful learning tool.

3. Increased student flexibility to practice based on their schedules. The learner can access the simulation at his or her convenience and is not required to practice the skills in front of an instructor, although that option remains available for those who need extra instruction or reinforcement. The learner can revisit a skill several times in an environment that is safe, nonthreatening, and conducive to learning.

4. Improved student instruction. Student instruction is improved through better consistency of teaching; increased learner satisfaction in both the classroom and the clinical setting; the opportunity for safer, nonthreatening practice of skills and decision making; and a state-of-the-art learning environment.

5. Effective competency check for undergraduates, new graduates, or new nurses going through orientation. The simulation experience provides a competency check of the participants’ knowledge, skills, and problem-solving abilities in a nonthreatening, safe environment.

6. Correction of errors discussed immediately. Students can learn by being immersed in their learning experience and then being debriefed after the encounter on what was right and what needed to be done differently.

7. Standardized, consistent, and comparable experiences for all students. Educators can create consistent, standardized teaching activities so that all students in a clinical 312course can experience an important clinical event, assessment activity, or other essential clinical learning encounter.

8. Opportunities for collaboration and IPE. This provides an avenue for safe and effective patient care through knowledge and understanding of other professionals’ roles and skills that all students in a clinical course can experience.

As educators are incorporating simulations into their courses and into the nursing curriculum, major challenges and benefits have been noted. Faculty must consider both challenges and benefits as the simulation pedagogy is adopted into courses and the nursing curriculum.



Planning to Use Simulations

Using simulations as a teaching–learning strategy requires advance planning. Planning should consider the need for resources, the overall curriculum, preparation of the student, and faculty development.



Operationalizing simulation requires physical space and equipment, the use of different types of simulation equipment and technology (manikins, virtual reality, Skype, electronic health records), faculty, and support staff. The physical space must be large enough to accommodate teaching and learning space, office space for faculty and staff, storage space, debriefing space, and, if used, space for video recording. Well-resourced spaces may mimic an acute care setting or operating room suite. Resources also include support staff who assist faculty in managing the equipment, and supporting the audiovisual technology.



Curriculum Considerations

A needs assessment and analysis should be performed to understand the intricacies of the curriculum in general and how the specific courses intersect with each other. Examining specific course content and the clinical site placements gives a broad overview of the types of experiences students are exposed to and how objectives are met. Further examination of QSEN competencies, national patient safety goals, the NCSBN Licensure Examination blueprint, the Institute of Medicine Initiatives, and standardized testing results can help design and pattern content for simulation. In thinking who the learners are, why they learn, what they learn, and how they learn, a schematic design for each course can be developed to determine how the goals of theory, simulation, and clinical are interconnected and where simulation would be appropriate.



Preparing the Student

Simulation is likely a learning strategy that is a new experience for the student. Faculty must orient the student to the use of the equipment and to his or her role as an active and engaged learner. Students must understand the learning goals, what assignments they should complete or information to have at hand during the simulation, how the simulation relates to the reality of clinical practice, and the significance of the debriefing session. If the simulation is being used for assessment or evaluation, faculty must provide an opportunity for students to become familiar with the equipment, and make clear the rubrics that will be used to judge performance.

Simulation supports students’ learning needs in a variety of ways. For example, simulations may offer a flexible, accessible opportunity to practice skills and interventions when student schedules permit. The learner can access the simulation at his or her convenience and not be required to practice the skills in front of an instructor, although that option can remain available for those who need extra instruction or reinforcement. Simulations also offer an opportunity to practice a selected skill set a number of times in an environment that is safe, nonthreatening, and conducive to learning. Simulations also provide exposure to real-life clinical experiences for students before caring for a specific type of patient in a specific type of clinical setting, thus giving them confidence when in the actual clinical setting.



Faculty Development

Educators prepared in the use of simulations are essential to the success of integrating simulations across the curriculum. However, unlike the traditional classroom setting, the faculty role when using simulations is no longer teacher-centered but rather is student-centered, with the educator assuming the role of a facilitator in the student’s learning process. The educator’s role during the simulation process varies, depending on whether the simulation is being conducted for learning or evaluation purposes. Educators must provide learner support as needed 313throughout the simulation and facilitate or guide the debriefing at the conclusion of the experience. If the simulation is being conducted for evaluation purposes, the teacher’s role changes to that of an observer and rater/grader.

When using simulations for the first time, faculty must feel comfortable with the simulations they are using. Pretraining on simulation pedagogy and debriefing is essential (National League for Nursing, 2015). Faculty may require assistance with simulation design, use of the technology, and setting up equipment for the activity. Whei Ming and Juestel (2010) found that novice faculty members needed assistance to operationalize the critical thinking learning objectives in a clinical simulation. To assist faculty, the educators developed a series of questions that provide direction about the specific thought processes involved in the application of the nursing process through the use of clinical simulations (Table 18-1).

Table 18-1

Critical Thinking Learning Objectives and Core Questions to Ask in Clinical SimulationsCritical Thinking Learning ObjectivesCore QuestionsAssess client to collect relevant data.

• Identify cues and make inferences.

• Validate data.

• What are the possible problems in this situation that need to be solved? On what evidence have you based your inferences?

• Is your evidence valid? What factors may alter the accuracy of the data? How would you validate each item of evidence?

• Why are these items relevant? How are they related?Diagnose actual and potential client health needs.

• Are the clustered data sufficient to support each diagnosis? What additional data do you need?

• Cluster data.

• Draw diagnostic conclusions.

• Are there different possibilities for clustering these data? Are there other alternative diagnoses that may fit different ways of clustering?

• What other data are needed to rule these possibilities in or out?Plan care based on identified client health needs.

• Set priorities.

• What are the most important problems that need to be solved? On what criteria did you base your decision?

• Predict outcome criteria.

• Generate solutions (interventions).

• What are the expected outcomes of the problem?

• What are the possible interventions for the problem described?

• What are the possible risks and benefits involved in each intervention?Implement plan of care.

• Test solutions.

• When do you assess the client’s response to each intervention? What are the desired responses to the intervention?Evaluate progress toward attainment of outcomes.

• If an adverse reaction happened, what would you do next? Why?

• Perform a criterion-based evaluation.Self-critique thinking strategies used to reach decisions.

• What were the factors influencing your thinking?

• Self-regulate thinking.

• What would you do differently in a different situation?

From Whei Ming, S., & Juestel, M. (2010). Direct teaching of thinking skills using clinical simulation. Nurse Educator, 35(5), 197–204.

Schools of nursing have found it helpful to send faculty to an orientation course or develop their own orientation to develop faculty for using simulations in their teaching. These courses include information about designing and using scenarios, the role of the faculty, and how to conduct the debriefing. Faculty experience a simulation first-hand as they participate in these courses.



Designing Simulations

Simulations should be carefully planned. The process of designing, implementing, and evaluating a simulation to support learning in nursing education is best done using a systematic, organized approach. To help nursing educators and researchers in this 314developmental process, a simulation framework (Jeffries, 2005) has been developed to identify the components of the process and their relationship to guide the design, implementation, and evaluation of these activities.


The Simulation Model

A framework (Fig. 18-1) has been designed by a national group organized by the National League for Nursing to assist educators in outlining the first steps of simulation development to provide a consistent and empirically supported model to guide the design and implementation of simulations as well as the assessment of learning outcomes when using simulations (Jeffries, 2005, 2012). Within the framework, five design features for developing a clinical simulation scenario are described. A simulation template used as a guide to develop the clinical simulations can be found at the Simulation Innovation Resource Center (SIRC) website at 18-1 Simulation model. Jeffries, P. R. (2012). Simulations in nursing education: From conceptualization to evaluation (2nd ed.). Philadelphia: Lippincott, Williams and Wilkins. (Used with permission.)

When developing the scenario, the design features are considered within the development process. For example, problem-solving components are considered in the scenario progression writing. Faculty can consider one or two problem-solving components designed in the scenario to be implemented by the novice students and three or four decision-making components for the more advanced student, perhaps to facilitate and emphasize prioritization at this level. After the simulation template is completed, it is advised that the scenarios be peer reviewed by content experts to ensure that evidence-based practices are being incorporated into the scenario and to confirm accuracy and that the content is up to date for today’s health care world. Finally, the scenario must be pilot-tested with targeted end users so that educators can ensure that the scenario is at the correct level for the learner and can review the scenario for sufficient decision-making points and cues to engage the students in the simulation. A variety of resources exist 315to provide educators with knowledge and skills on developing simulation scenarios, including regional and national workshops, conferences, instructor courses, and several publications (Campbell & Daley, 2008; Guhde, 2011; Jeffries, 2007; Simulation Innovation Resource Center [SIRC], n.d.).



Evidence-based Debriefing and Reflection

Debriefing is one of the key design features to consider when developing a simulation (see Fig. 18-1). Debriefing is a process by which educators facilitate learners’ reflection or reexamination of clinical encounters (Dreifuerst, 2009, 2012). Ideally, debriefing should be twice as long as the scenario and involves active participation from all learners (caregivers to observers), where the learners do most of the talking. The debriefing environment should be a safe environment where learners can engage in meaningful discussion. Debriefing in the context of simulation involves reflective observation and abstract conceptualization. Reflective observation has its roots in Gestalt psychology and in the works of Lewin (1951); Schön (1987); Diefenbeck, Plowfield, and Herrman (2006); and Kolb (1984). Kolb (1984) and others (Sewchuck, 2005; Svinicki & Dixon, 1987) suggest that the experiential learning cycle is a continuous process in which knowledge is created by transforming experience. Individuals have a concrete experience, they reflect on that experience (reflective observation), they derive meaning (abstract conceptualization) from the experience, and they try out or apply (active experimentation) the meaning they have created, thus continuing the cycle with another concrete experience. Debriefing encompasses the cognitive domain assessing knowledge; the kinetic domain assessing skill and action; and the affective domain, or how the learner felt or interacted with the patient or other staff.

The role of faculty in facilitating simulation exercises is to support participants in the reflection and debriefing process. Objectives of debriefing include the opportunity for the learners to describe what the experience was like for them; this includes a release of emotional tension about the experience, a guided review of the patient and objectives, the identification and sorting of thinking, and reinforcement of teaching and correction of misconceptions. Debriefing is an opportunity to reference real-life experiences, normalize behaviors, and acknowledge emotions.

Debriefing strategies are varied and several models are used in the simulation setting (Cheng et al., 2014; Simon, Rudolph, & Raemer, 2009; Waznonis, 2014). The National League for Nursing in its Vision Statement, Debriefing Across the Curriculum, recommends that faculty use evidence-based resources to develop their skills in debriefing (National League for Nursing, 2015). The Debriefing Assessment for Simulation in Healthcare (DASH) tool is designed to evaluate and develop the debriefing skills of the facilitator. This tool evaluates the facilitators’ ability to conduct debriefings following specific behaviors. It is an evidence-based tool designed according to how people learn and change in experiential learning and was vetted by an expert panel at Harvard ( Table 18-2 depicts one debriefing model (Overstreet, 2010).

Table 18-2

Components for Debriefing Nursing Students Using the Ee-ChatsDebriefing ComponentEducator Action/Activity/StrategyE—EmotionFaculty need to address learners’ emotions that have been stimulated during the simulation encounter; encourage the students to translate emotions into words.e—ExperienceFaculty can briefly share their experiences or stories; inform the students how the expert would have handled the situation—but be brief, this is only one small part of debriefing.C—CommunicationEducators should talk less and students more; students also can observe your verbal and nonverbal messages; the debriefing should be a positive experience.H—Higher Order of ThinkingStudents should be encouraged to reflect in, on, and beyond the simulation encounter they have experienced; how will this experience translate into the clinical one?A—Accentuate the PositiveEducators need to be positive when conducting a debriefing—reframe and rephrase your questions into inquiry-time ones, not blaming. Focus on behaviors that are professional and essential.T—TimeAllow students time to formulate their responses and reflections. Embrace silence.S—StructureDebriefing time should focus on the encounter, the events, actions, and behaviors demonstrated in the simulation.

From Overstreet, M. (2010). Ee-chats: The seven components of nursing debriefing. The Journal of Continuing Education in Nursing, 41(12), 538–539.

Facilitators face challenges in debriefing, including blame-setting for performance, statements such as “this wouldn’t happen in real clinical,” learners who are open with dislike about the learning environment, learners who are hostile and defensive or who are self-critical and defeated based on performance. Facilitators provide a safe, nonjudgmental environment and coach students to reflect on what they saw, heard, and experienced. All debriefings should be well planned and structured. The key for faculty during debriefing is not to provide more information or to lecture on the “correct” way or answer, but to guide students along the path of reflection. Open-ended questions, silence, and pauses help elicit feedback from learners and encourage active participation. Identification of a “take-away” message or transfer of learning to other situations should be included (Lusk & Fater, 2013).



Implementing Simulations

Once the simulation is designed, faculty members are ready to implement it into the nursing course. The following guidelines may be useful to educators implementing simulations into their nursing courses:


1. Make sure specific objectives match the implementation phase of the simulation. When faculty design a simulation, the objectives and nature of the simulation should be clearly defined for the students and facilitator. Furthermore, if the simulation is designed, for example, around the care of an 316insulin-dependent patient, then the scenario should be created using problems typically encountered and the problem-solving skills needed for that patient’s care. The simulation should focus on the objectives and not on potential co-morbidities or extraneous issues.

2. Set a time limit for the simulation and the debriefing encounter and then adhere to it. Too often instructors observe that in simulations students are immersed for a specific time limit but are not able to accomplish all of the assessments and interventions the instructor had desired. At times instructors may let the scenario proceed beyond the specific time frame; however, if the simulation is scheduled for 20 minutes, the encounter needs to be 20 minutes. If students do not achieve the objectives desired, the reflective observation time can be spent on their experiences and the meaning they make of them.

3. Implement an appropriate orientation of students to the simulation labs where they will be interacting with the simulators. This is an important step to help eliminate the anxiety and fear of the unknown associated with initial exposure to simulation as a whole. It is also important to engage in a confidentiality agreement with the students that makes debriefing a safe environment for students and faculty, and lastly, implement a fiction contract where students are expected to treat the simulation environment as they would a true clinical encounter.

4. In undergraduate nursing programs, it is advisable to make assignments so students know their specific roles during the simulation. Unless developing or testing team leadership skills, students need roles (e.g., nurse, observer, family member) assigned before encountering the simulation to bring organization to the experience. If roles are not assigned, students waste time trying to decide what role to play. In advanced practice nursing programs, role delineation may be handled by the students. It is conceivable that advanced practice nurses can come together to determine specific roles and responsibilities. This may also be a good topic to investigate during postsimulation debriefing.

5. Avoid interrupting the simulated encounter when students are trying to problem-solve on their own. In simulation, the learners function as professionals, not as students, so they are asked to step beyond their comfort zone and interact in the scenario without someone directing them how to act. Facilitators should observe a simulation remotely, either behind a one-way mirror 317or via closed-circuit television, so students cannot see facial expressions, hear comments, or see nonverbal gestures. It is best for faculty to discuss the points of concern, prioritization, and problem-solving issues during the debriefing immediately after the simulation event. If this is not done in the immediacy of the simulation, the behaviors can be forgotten or confused with other scenarios.

6. Involve a limited number of learners in the simulation experience in addition to one or two observers or recorders of the encounter. Typically, two to six students are each assigned a role in the simulation experience. The roles within the simulation need to be identified before and recognized during the simulation. For example, students can wear name tags or labels and appropriate clothing for particular roles or have certain props available to help delineate the roles. When an educator has more students than are needed to participate in the simulation, these students can be assigned an observer role.

7. Ensure that the simulation is appropriate for the learners’ skill levels and cognitive ability. Although a prominent design feature when developing simulations is fidelity, simulations need to be realistic to the degree that matches the learning level of the student group. Early on in exposure to the simulation environment, students benefit from scenarios that are comparable to their didactic learning. Low- or medium-fidelity manikin and standardized patients with basic care needs offer opportunities to focus on basic skill and knowledge acquisition. Failure and anxiety in the simulation scenario can occur when the simulation objectives include skills or competencies students have not learned (e.g., IV management prior to IV curriculum or altered cardiac or lung sounds prior to cardiac or lung modules). As exposure to the simulated environment increases, learners benefit from a higher level of complexity and a mix of fidelity, including challenges found in a complex environment such as simulated emergent events that involve critical thinking, active interaction, teamwork, and collaboration with the health care team to achieve a common goal. Simulations assist students at the application level of learning to practice their decision-making, problem-solving, and team member skills in a nonthreatening environment. The environment needs to be sufficiently realistic to allow for suspension of disbelief, so that the transition of knowledge from theory to practice can be stimulated. In simulation there is no “pretend.” All necessary equipment should be available and standards and protocols should be followed to mimic the clinical setting. If a patient is to take a medication, the proper steps for administration should be used.

8. When planning to incorporate simulations into the course or curriculum, ensure that faculty development is included in the planning. Faculty need to know how to conduct a simulation and a debriefing session to achieve the desired outcomes with the teaching–learning strategy. Faculty need to be prepared to design and conduct simulations in the educational setting before they are actually placed in the learning laboratory or clinical practicum with students in a simulation situation. All faculty members using this type of strategy in their classroom or clinical instruction need to be aware of and clear about the purpose of the simulation activity. At the end of the simulation, a clear summary and highlights need to be included by all instructors, particularly if there are several educators using the same simulation in a course. Discussion about simulations and how to implement them and clarity on learning outcomes for the simulation are needed and must be agreed on by faculty before implementation of the simulation. Clear delineation of the objectives of the scenario and the debriefing model should be followed by all facilitators. A predesigned concept map for each scenario can help guide facilitators for consistent debriefing.


Integrating Simulations into Courses and Curricula

Simulations can be integrated into nursing courses, laboratory experiences, and clinical courses to promote more active and experiential learning at 318most schools of nursing (Katz et al., 2010). As more schools adopt clinical simulations in their courses and curricula and as actual clinical experiences are becoming more difficult to obtain, some faculty and their state boards of nursing are supplementing or substituting clinical time with simulations.

More recently, following the trend in electronic communications for teaching and students’ strong acceptance of online learning, more sophisticated technologies have enabled simulation approaches to transition from the classroom to a virtual platform.

Virtual simulation in online nursing education combines the pedagogy of face-to-face simulation with electronic multimedia options to produce activities that are both interactive and mediated by the learner. Virtual simulation programs can be hosted online and accessed using a choice of navigable software using learning objectives that vary from highly focused technical skills training to broader, case-based patient scenarios that require critical thinking and clinical decision making (Cant & Cooper, 2014). Some popular virtual simulation software products available for online nursing education include ArchieMD, CliniSpace, Second Life, TINA, Virtual Heroes, and vSim.

Faculty have integrated simulations in a variety of courses. Thomas, Hodson-Carlton, and Ryan (2010) used clinical simulations in a senior leadership course to better prepare and facilitate new graduates to clinical practice. Clinical scenarios were developed that incorporated students, faculty, staff, and community volunteers who role-played situations that students may encounter after graduation. Some of the issues embedded in the scenarios include staffing problems, physician interactions, patient and family communications, and crisis interventions.

Hamilton (2010) used clinical simulations during academic and clinical experiences to equip students with the skills necessary to productively cope with the stressors faced in difficult end-of-life situations. Using the End-of-Life Nursing Education Consortium materials, the educator found simulations to be an effective teaching strategy to identify anxiety levels prior to clinical experience and as a venue for exploring learning and coping styles.

Maternity simulators have been used to teach students about maternal and child health. Undergraduate faculty from a large Midwest nursing program implemented a 6-hour laboratory and virtual clinical experience for students in the maternal–newborn health rotation that incorporated various simulations (Bantz, Dancer, Hodson-Carlton, & Van Hove, 2007). This experience consisted of eight stations, including assessment of the postpartum fundus, newborn assessment and care (with a SimBaby), newborn nutrition, labor, and birth (with the Noelle birthing simulation manikin), fetal heart rate assessment and interpretation, Leopold’s maneuvers, and computerized charting. According to Bantz et al. (2007), the majority of students who participated in this clinical laboratory experience indicated that they felt better prepared to provide nursing care to newborns and their mothers in the clinical site.

DeBourgh and Prion (2010) used a quasiexperimental pretest and posttest study of 285 prelicensure students to teach students fall prevention and patient safety using clinical simulations with standardized patients. The results of the teaching and research conducted concluded that the simulation learning experience provided students with knowledge and skill gains they could apply to clinical practice.

Thompson and Bonnel (2008) integrated the use of high-fidelity simulation in an undergraduate pharmacology course to provide an applied learning experience where students could make connections between learned content and clinical application. An experience of safe medication administration has been added to both pharmacology course simulations and any simulation in which the “patient” is to receive medications.

Rosenzweig, Hravnak, and Magdic (2008) developed a patient communication simulation experience for the acute care nurse practitioner students at a major university to evaluate students’ perceived confidence and communication effectiveness before, immediately after completion, and 4 months after completion. Results showed that the content and methods used for the simulation experience improved students’ confidence and perceived skill in communication in difficult acute care situations.

As distance education course formats proliferate in nursing curricula, simulation has been recognized as a potentially rich learning strategy. Nelson and Blenkin (2007) used online role-play simulation to provide students with the opportunity to learn professional and personal relationships in an online environment. The online learning platform provided students with a learning opportunity to deal with difficult behavior and to manage violence, abuse, and patients with dementia. To initiate the learning activity, the authors built what was called a “kickstart” episode, in which students would have to react to a significant 319event, for example, a patient dying. Participating students logged in and played their assigned roles, which ranged from long-term care residents to facility staff members. During the computer-based event, students role-playing as health care professionals could enter into an “interaction space (ispace)” where a threaded discussion could occur about the patient’s problem. Several resources were available to students within the online simulation environment, including instruction sheets and video clips to assist the students with the care of these selected patients. Students immersed themselves in the online simulations and believed that the level of realism paralleled clinical nursing practice and offered a relevant student learning experience.

Unfolding case simulations are gaining more attention in nursing programs. Durham and Sherwood (2008) used unfolding simulated cases to teach quality and safety concepts and how these concepts are integrated into nursing practice. In addition, Batscha and Moloney (2005) used online unfolding case studies to facilitate nursing students to analyze, organize, and prioritize in novel situations. Finally, Azzarello and Wood (2006) suggest that unfolding cases can be used to evaluate students’ changing mental models because they offer a practical strategy for revealing flaws in students’ problem solving that would otherwise not be obvious. Unfolding cases are not limited to the traditional simulation laboratory. Innovative use of unfolding cases has the potential to transform traditional teacher-centered classrooms into interactive, engaging learning environments that support the flipped classroom (Educause Learning Initiative, 2012). The notion of the unfolding cases fit very well when teaching in the connected and “flipped” classroom (see Chapter 19).





Evaluation Considerations when Using Simulations

Evaluation of the Design and Development Phase of Simulation

To evaluate the design and development of simulations created by nurse educators, Jeffries (2005) developed the Simulation Design Scale (SDS). The purpose of this tool is to provide the educator with information and feedback that can be used to improve the simulation design and implementation. The SDS is a 20-item tool that the learner completes after participating in a simulation to provide feedback on whether the intended simulation design features were present. These features include the objectives and information, support, problem solving, feedback and debriefing, and fidelity. These are referred to as simulation design features because they define what a quality simulation requires if it will have a positive effect on learning outcomes. Content validity of this instrument was determined by a panel of nine nurse experts. Cronbach’s alpha was computed to assess internal consistency reliability for each scale. The coefficient alpha for the overall scale was 0.94. Table 18-3 briefly describes the SDS’s five components.

Table 18-3

Simulation Design Scale ComponentsConcept and Design FeaturesDescription of ConceptInformation/objectivesClear objectives and timeframe for the simulation is information needed by the student before the simulation begins.Problem solving/complexityThe simulation needs to be designed with problem-solving components embedded in the written scenario or case. The level of problem solving needs to be considered; for example, use simple tasks and decisions if students are in a fundamentals course versus more complex tasks if students are in an upper-level course and are 6 months away from graduating.Student support/cuesStudent support in a simulation is offered before, during, and after. Support includes providing information and direction to the student before the simulation.FidelityA simulation should be as close an approximation as possible to the real event or activity that is being modeled to promote better learning outcomes.Guided reflection/debriefingGuided reflection reinforces the positive aspects of the experience and encourages reflective learning, which allows the participant to link theory to practice and research, think critically, and discuss how to intervene professionally in very complex situations.

From Jeffries, P. R. (2007). Simulations in nursing education: From conceptualization to evaluation. New York: The National League for Nursing. (Used with permission.)



Evaluation of the Implementation Phase

When simulations are implemented, particular components need to be included to ensure good learning experience, student satisfaction, and good learner performance. According to Chickering and Gamson (1987, 1991), incorporating the Principles of Best Practice in Education assists educators to implement quality teaching activities and improve student learning. As a component of the simulation model (Jeffries, 2005), those educational practices are considered very important in the implementation of simulations in the students’ learning environment. To measure this component, the Educational Practices in Simulation Scale (EPSS) was developed. The EPSS is a 16-item tool that the learner completes after a simulation. This tool measures whether the best practices in education, according to Chickering and Gamson (1987), are being used in the simulation. All seven educational practices in simulation are being evaluated; however, after conducting a factor analysis on the scale, four factors were identified and several of the factors were collapsed into these four components of the scale. Therefore the elements being evaluated in the EPSS are active learning, diverse ways of learning, high expectations, and collaboration, as shown in Table 18-4. The questionnaire was tested for validity and reliability. Content validity was established through a review by nine nursing experts. The coefficient alpha was 0.92.

Table 18-4

Educational Practices in Simulation ScaleComponents of the EPSSDescription of Components within the ScaleExamplesActive learningThrough simulation, learners are directly engaged in the activity and obtain immediate feedback and reinforcement of learning. Learning activities can range from simple to complex.A case scenario in which an intubated patient is restless, agitated, and coughing, affecting his oxygenation status. Students can be asked to select the most appropriate intervention and describe the rationale for the intervention.Diverse styles of learningSimulations should be designed to accommodate diverse learning styles and teaching methods and allow students and groups with varying cultural backgrounds to benefit from the experience.Design a scenario that has visual, auditory, and kinesthetic components.High expectationsHigh teacher expectations are important for the student during a learning experience because expecting the student to do well becomes a self-fulfilling prophecy.Set up a scenario with multiple patient problems to challenge the learner and to advance learning and skill application to the next level.CollaborationCollaboration is pairing students in a simulation to work together. Roles are assigned so that students jointly work on the problem-solving and decision-making skills within the simulation together.Assign a student the role of a primary nurse and a third-year medical student the role of a physician. Place the two students in a setting where they will be confronted with a patient having postoperative complications that requires quick assessments and efficient decision-making skills to intervene appropriately with the patient.

From Jeffries, P. R. (2007). Simulations in nursing education: From conceptualization to evaluation. New York: The National League for Nursing. (Used with permission.)



Evaluation of Learning Outcomes

As discussed previously, learning outcomes can be measured through low-stakes and high-stakes simulations. Outcomes are defined for the learning activity and can be measured by a well-designed clinical simulation. Research in this area is growing as educators measure the outcomes of the simulation activity desiring to close the knowledge and skills gap within academe and practice. Some instruments available for evaluation include the Laseter Clinical Judgment Rubric (Laseter, 2007) and the Seattle University Evaluation Tool, and the Creighton Evaluation Instrument (Hayden, Keegan, Kardong-Edgren, & Smiley, 2014). Limited valid and reliable grading checklists for the evaluation of high-stakes simulation exist. Scoring checklists are an emerging area of research in simulation 321pedagogy that have been developed and tested for validity and reliability; an example is a checklist for use during perioperative emergency simulation training (McEvoy et al., 2014). Evaluation tools for clinical simulation training are evolving.




Educators use simulations to enhance learning outcomes and promote safe patient care environments. Nursing organizations, commissions of higher education, accrediting bodies, academic institutions, and schools of nursing are seeking answers to questions about simulation design and development, teaching and learning practices, implementation processes, and associated learning outcomes. Educators and researchers must join forces to develop more rigorous research studies testing simulation outcomes. National, multisite simulation studies by nurse educators are currently being conducted to enhance understanding of the educational usefulness of nursing simulations. For example, when simulations are used as a teaching–learning intervention, are learning outcomes improved? When developing a simulation, what are the important design features of a well-executed simulation in nursing education? How can simulations be used to prepare for or replace clinical experience? How does the use of simulations contribute to advancing nursing into the next generation? Educators need to make certain they are informed about the possibilities of simulations, their usefulness in enhancing student education, and the progress of educational research efforts conducted to develop and test new models of using simulation in nursing education.

Reflecting on the evidence

1. What evidence is available on the effectiveness of using simulation in support of learning?

2. When using a simulation framework, how would you construct a research project to test the framework?

3. Identify three research questions that might be addressed when studying reflective observation.

4. What is the optimal balance of simulated versus actual clinical practice in nursing education?


Adamson K.A. Evaluation tools and metrics for simulations. In: Jeffries P.R., ed. Clinical simulations in nursing education: Advanced concepts, trends, and opportunities. Philadelphia: Wolters Kluwer; 2014:145–164 chapter 12.

Alden K.R., Durham C.F. Integrating reflection in simulation: Structure, content, and processes. In: Sherwood G., Horton-Deutesch S., eds. Reflective practice: Transforming education and improving outcomes. Indianapolis: Sigma Theta Tau International; 2012:149–168.

Alinier G., Harwood C., Harwood P., et al. Immersive clinical simulation in undergraduate health care interprofessional education: Knowledge and perceptions. Clinical Simulation in Nursing. 2014;10:e205–e216.

Anderson J.M., Warren J.B. Using simulations to enhance the acquisition and retention of clinical skills in neonatology. Seminars in Perinatology. 2011;35:59–67. doi:10.1053/j.semperi.2011.01.004.

Azzarello J., Wood D.E. Assessing dynamic mental models: Unfolding case studies. Nurse Educator. 2006;31(1):10–14.

Bantz D., Dancer M., Hodson-Carlton K., Van Hove S. A daylong clinical laboratories: From gaming to high fidelity. Nurse Educator. 2007;32(6):274–277.

Batscha C., Moloney B. Using PowerPoint to enhance unfolding case studies. Journal of Nursing Education. 2005;44(8):387.

Boulet J.R., Swanson D.B. Psychometric challenges of using simulations in high-stakes assessment. In: Dunn W.F., ed. Simulation in critical care and beyond. Des Plains, IL: Society of Critical Care Medicine; 2004:119–130.

Campbell S., Daley K. Simulation scenarios for nursing educators: Making it real. New York: Springer; 2008.

Cant R., Cooper S. Simulation in the Internet age: The place of web-based simulation in nursing education. An integrative review. Nurse Education Today. 2014;34:1435–1442.

Chambers K., Boulet J., Gary N. The management of patient encounter time in a high-stakes assessment using standardized patients. Medical Education. 2000;34:813–817.

Cheng A., Eppich W., Grant V., Sherbino J., Zendejas B., Cook D.A. Debriefing for technology-enhanced simulation: A systematic review and meta analysis. Medical Education. 2014;48(7):657–666.

Chickering A.W., Gamson Z.F. Seven principles for good practice in undergraduate education. AAHE Bulletin. 1987;39(7):3–7.


Chickering A.W., Gamson Z.F. Applying the seven principles for good practice in undergraduate education. New Directions for Teaching and Learning. 1991;47.

Cook M.J. Design and initial evaluation of a virtual pediatric primary care clinical in Second Life. Journal of the American Academy of Nurse Practitioner. 2012;24(9):521–527.

DeBourgh G.A., Prion S. Using simulation to teach prelicensure nursing students to minimize patient risk and harm. Clinical Simulation in Nursing. 2010;6(1):e1–e210.

Diefenbeck C.A., Plowfield L.A., Herrman J.W. Clinical immersion: A residency model for nursing education. Nursing Education Perspectives. 2006;27(2):72–79.

Dismukes R.K., Gaba D.M., Howard S.K. So many roads: Facilitated debriefing in healthcare. Simulation in Healthcare. 2006;1(1):23–25.

Dreifuerst K. The essential of debriefing in simulation learning: A concept analysis. Nursing Education Perspectives. 2009;30(2):109–114.

Dreifuerst K.T. Using debriefing for meaningful learning to foster development of clinical reasoning in simulation. Journal of Nursing Education. 2012;51(6):321–333.

Dunn W.F. Simulators in critical care and beyond. Des Plaines, IL: Society of Critical Care Medicine; 2004.

Durham C., Sherwood G. Education to bridge the quality gap: A case study approach. Urological Nursing. 2008;28(6):431–438.

Educause Learning Initiative. Seven things you should know about flipped classrooms. 2012. Retrieved from http://net.educause.Edu/ir/library/pdf/eli7081.pdf.

Engum S., Jeffries P.R. Intravenous catheter training system: Computer-based education versus traditional learning methods. The American Journal of Surgery. 2003;186(1):67–74.

Farra S., Miller E., Timm N., Schafer J. Improved training for disasters: Using 3-D virtual reality simulation. Western Journal of Nursing Research. 2013;35(5):655–671.

Guhde J. Nursing students’ perceptions of the effect on critical thinking, assessment, and learner satisfaction in simple versus complex high-fidelity simulation scenarios. Journal of Nursing Education. 2011;50(2):73–78.

Halstead J. Evidence-based teaching and clinical simulation. Journal of International Nursing Association of Clinical Simulation. 2006;2(1):1–6.

Hamilton C.A. The simulation imperative of end-of-life education. Clinical Simulation in Nursing. 2010;6(4):e131–e138.

Hayden J., Keegan M., Kardong-Edgren S., Smiley R.A. Reliability and validity testing of the Creighton Competency Evaluation Instrument for use in the NCSBN National Simulation Study. Nursing Education Perspectives. 2014, July–August;35(4):244–252.

Hayden J., Smiley R., Alexander M.A., Kardong-Edgren S., Jeffries P. The NCSBN National Simulation Study: A longitudinal, randomized, controlled study replacing clinical hours with simulation in prelicensure nursing education. Journal of Nursing Regulation. 2014a;5(2):S3–S40.

International Nursing Association for Clinical Simulation and Learning (INACSL) Board of Directors. Standards of best practice: Simulation: Standard 1: Terminology. Clinical Simulation in Nursing. 2011;7(Suppl):S3–S7. doi:10.1016/j.ecns.2011.05.005.

Jeffries P.R. A framework for designing, implementing, and evaluating simulations used as teaching strategies in nursing. Nursing Education Perspectives. 2005;26(2):96–103.

Jeffries P.R. Simulations in nursing education: From conceptualization to evaluation. New York: The National League for Nursing; 2007.

Jeffries P. Simulation in nursing education: From conceptualization to evaluation. 2nd ed. Philadelphia: Lippincott Williams and Wilkins; 2012.

Jeffries P.R., Hovancsek M.T., Clochesy J.M. Using clinical simulations in distance education. In: Novotny J.M., Davis R.J., eds. Distance education in nursing. 2nd ed. New York: Springer; 2005:83–99.

Jeffries P.R., Woolf S., Linde B. Technology-based vs. traditional: A comparison of two instructional methods to teach the skill of performing a 12-lead ECG. Nursing Education Perspectives. 2003;24(2):70–74.

Katz G.B., Peifer K.L., Armstrong G. Assessment of patient simulation use in selected baccalaureate nursing programs in the United States. Simulation in Healthcare. 2010;5(1):46–51.

Kolb D.A. Experiential learning. Upper Saddle River, NJ: Prentice-Hall; 1984.

Laseter K. Clinical judgment using simulations to create an assessment rubric. Journal of Nursing Education. 2007;46(11):496–503.

Lewin K. Field theory in social science. New York: Harper & Row; 1951.

Lusk J.M., Fater K. Postsimulation debriefing to maximize clinical judgment development. Nurse Educator. 2013;38:16–19. doi:10.1097/NNE.ObO13e318276df8b.

MacDonald M.B., Bally J.M., Ferguson L.M., Murray B.L., Fowler-Kerry S.E., Anonson J.M.S. Knowledge of the professional role of others: A key interprofessional competency. Nurse Education in Practice. 2010;10:238–242.

McEvoy M.D., Hand W.R., Furse C.M., Field L.C., Clark C.A., Moitra V.K., et al. Validity and reliability assessment of detailed scoring checklists for use during perioperative emergency simulation training. Simulation in Healthcare. 2014;5:295–303. doi:10.1097/SIH.0000000000000048.

Meyer M.N., Connors H., Hou Q., Gajewski B. The effect of simulation on clinical performance. Simulation in Healthcare. 2011;6(5):269–277. doi:10.1097/SIH.Ob013e318223a048.

Miller C.L., Leadingham C., Vance R. Utilizing human patient simulators (HPS) to meet learning objectives across concurrent core nursing courses: A pilot study. Journal of College Teaching & Learning. 2010;7(1):37–43.

National League for Nursing. Debriefing across the curriculum. 2015. Retrieved from

Nelson D.L., Blenkin C. The power of online role-play simulations: Technology in nursing education. International Journal of Nursing Education Scholarship. 2007;4(1):1–12.

Newton C., Bainbridge L., Ball V., et al. The Health Care Team Challenge™: Developing an international interprofessional education research collaboration. Nurse Education Today. 2014;1:1–5.

Overstreet M. Ee-chats: The seven components of nursing debriefing. The Journal of Continuing Education in Nursing. 2010;41(12):538–539.

Page J.B., Kowlowitz V., Alden K.R. Development of a scripted unfolding case study focusing on delirium in older adults. Journal of Continuing Education in Nursing. 2010;41(5):225–230.


Reese C., Jeffries P.R., Engum S. Learning together: Using simulations to develop nursing and medical student collaboration. Nursing Education Perspectives. 2010;31(1):33–37.

Reising D., Hensel D. Clinical simulations focused on patient safety. In: Jeffries P., ed. Clinical simulations in nursing education: Advanced concepts, trends, and opportunities. Philadelphia: Wolters Kluwer; 2014.

Richardson H., Goldsant L., Simmons J., Gilmartin M., Jeffries P. Increasing faculty capacity: Findings from an evaluation simulation clinical teaching. Nursing Education Perspectives. 2014. Retrieved from .

Rosenzweig M., Hravnak M., Magdic K. Patient communication simulation laboratory for students in an acute care nurse practitioner program. American Journal of Critical Care. 2008;17:364–372.

Ryan C.A., Walshe N., Gaffney R., Shanks A., Burgoyne L., Wiskin C.M. Using standardized patients to assess communication skills in medical and nursing students. BMC Medical Education. 2010;10(24):1–8.

Schön D.A. Educating the reflective practitioner. San Francisco: Jossey-Bass; 1987.

Seefeldt T., Mort J., Brockevelt B., Giger J., Jorde B., Lawler M., et al. A pilot study of interprofesssional case discussions for health professions students using the virtual world Second Life. Currents in Pharmacy Teaching and Learning. 2012;4(4):224–231.

Sewchuck D.H. Experiential learning—A theoretical framework for perioperative education. AORN Journal. 2005;81(6):1311–1318.

Simon R., Rudolph J.W., Raemer D.B. Debriefing assessment for simulation in healthcare—Rater version. Cambridge, MA: Center for Medical Simulation; 2009.

Simulation Innovation Resource Center (SIRC). (n.d.) Homepage. Retrieved from

Svinicki M.D., Dixon N.M. The Kolb model modified for classroom activities. College Teaching. 1987;35(4):141–146.

Thomas C., Hodson-Carlton K., Ryan M. Preparing nursing students in a leadership/management course for the workplace through simulations. Clinical Simulation in Nursing. 2010;6(1):e1–e6.

Thompson T.L., Bonnel W. Integration of high-fidelity simulation in an undergraduate pharmacology course. Journal of Nursing Education. 2008;47(11):518–521.

Waznonis A. Methods and evaluations for simulation debriefing in nursing education. Journal of Nursing Education. 2014;53(8):459–465.

Whei Ming S., Juestel M. Direct teaching of thinking skills using clinical simulation. Nurse Educator. 2010;35(5):197–204.

Wilson M., Shepherd C., Pitzner K.J. Assessment of a low-fidelity human patient simulator for the acquisition of nursing skills. Nurse Education Today. 2005;25(1):56–67.