For simulation to be beneficial the education providers themselves require education on organizing simulation, if it is to be of benefit to the students. Many facilities anecdotally report that high fidelity simulation manikins are under-utilized due to lack of knowledge of the educators related to setting up and running simulated scenarios and skills.
An analysis by McGaghie et al (2009) related to the value of medical education and simulation revealed that simulation certainly has a place in educating medical students however, low or high fidelity simulation technology will be ineffective or misused unless faculty members, including physicians and other health professionals, are suitably prepared as simulation educators. Related to faculty development, especially about the effective use of simulation technology to promote learner achievement, must become a priority training goal. Although this was a comprehensive review it has the potential for bias as one of the authors is a frequent speaker at conferences funded by manufacturer of simulation equipment. An educational study by Jeffries (2005) characterize simulations as activities that imitate the reality of a clinical environment, are designed to demonstrate procedures, decision-making, and critical thinking through techniques such as role playing and the use of devises such as interactive videos or mannequins. Simulation offers a range of patient care experiences to the student in certain circumstances that are either too rare or too risky for them to participate in. Additionally the declining number of clinical placements that are open to nursing students is a concern in many countries (Curl et al 2007). A report by McGillis et al (2004) advised that the level of patient acuity has risen exposing students to high acuity patients early in their education. As students prepare to enter the clinical area efforts are made to make sure that the students are prepared, including consideration of the learning styles of individual students. Grady et al (2008) conducted a study on clinical simulations and learning styles and concluded that student’s cognitive, psychomotor, learning domains and preferences can be accomplished through clinical simulations. Comer (2006) conducted a similar study and also confirms that different learning styles can be accommodated including visual learners observing the clinical situation and observing each other through role modeling.
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In 2006 the National League of Nursing in conjunction with Laerdal (manufacturers of high fidelity manikins) conducted a multi-site and multi method study exploring simulation as a teaching strategy. The findings suggested that students who were involved in high fidelity simulation had greater satisfaction with their learning and reported they were more confident when making decisions and implementing patient care.
Nehring et al (2001) studied the efficacy of simulation on cognitive knowledge acquisition using a pre-test/post-test design and validated that students gained and retained considerable cognitive knowledge from simulation practice.
Conversely, Jeffries et al (2006) compared three types of simulations “paper-and-pencil, static manikin, and high-fidelity manikin” and found no differences among the three groups when cognitive knowledge levels were measured. The author’s propose that cognitive change is not a sufficient assessment method to use when evaluating performance in high-fidelity simulation. A comparison study on medical education conducted by the Agency for Healthcare Research and Quality Evidence Report AHRQ (2006) indicate that simulation training is effective, especially for psychomotor and communication skills, however the strength of the evidence is low. The authors suggest that research should focus on valid and reliable tools for more systematic outcome measurements, focusing on improving the quality of patient care. The AHRQ (2006) reports that simulation will never replace the situational perspective and complex interactions learned through contact with real patients.
The challenge faced by nurse educators in assisting students to make the transition from simulation to clinical practice remains a concern. Reviewing the literature on the subject of assessment of students’ abilities in the traditional clinical practice setting has a number of well-documented limitations.
Shell’s (2001) study demonstrates that faculty/student ratios did not always provide opportunities to observe students making clinical judgments and Gubrud et al (2008) found clinical experiences that allowed for observation of the development of clinical judgment skills were haphazard.
More recently, Lasater (2007) provided evidence that High-fidelity simulation (HFS) allows for a more comprehensive evaluation of the development of students’ clinical judgment as well as recognition of gaps in their understanding of clinical practice.
Transference of simulation to practice
Recent studies by Grantcharov et al (2008), DeYoung (2003), Knight (1998) all concluded that restructuring of clinical skills laboratories needs consideration regarding more practical time and less theoretical content and that more research needs to be conducted to evaluate the changes. A rigorous search of the literature was conducted to find results to support the transference of simulation to practice. Multiple studies Alinier et al., (2006); Bremner et al., (2006) Jeffries, (2008), revealed that there was no standardized curriculum developed for simulation use, the authors also felt that a standardized method for evaluating student learning in simulation would be beneficial. Alinier et al., (2006); Bremner et al., (2006) Jeffries, (2008) concur that a safe, supportive, well-planned and debriefed simulation can be a successful clinical experience since they facilitate the application of critical thinking and judgement, which is often overshadowed in practice due to the complexity of care and the need to complete tasks in a timely manner. Also revealed was that task-oriented clinical times, were of little benefit to the students because they were not learning the role of the practised professional nurse.
Solutions: Making it work in the future
Due to the increasing sophistication of technology educational facilities and nurse educators have a responsibility to keep up to date with the latest technologies. As previously stated with decreased number of clinical sites available Commission on Education, (2007); Dugan & Amorim, (2007); Magnusson, O’Driscoll, & Smith, (2007), nurse educators need to assess available technologies to best understand how they can prepare prospective nurses for practice. Additional research will assist with documentation of the effectiveness of high-fidelity simulation and identify best practices for its use in nursing education.
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One framework that could impact on the education of both medical and nursing students is the Progressive Professional Development Model (PPDM) developed by Notarianni et al (2009). This model is designed to guide educators to plan learning experiences that promote development in all the domains of learning. PPDM combines the use of standardized patients, computer and simulated practice settings with traditional clinical practice. The assumption of this model is to provide opportunity for the learner to encounter similar experiences that have a variety of contextual difference with the aim of facilitating the learner’s progress from beginner to professional Benner (2004).
A major benefit is that the learner is able to translate learning into practice; providing a safe, supportive, experience that can enhance the learner’s transition from simple to complex problem-solving. Notarianni et al (2009) suggests that potential for application measures a model’s value and the successful implementation of PPDM depends on considering multiple factors.
Ensuring that all necessary resources and supports are accessible will assist with ensuring a smoother implementation of PPDM including instructional technology and support, appropriately equipped laboratories and suitably qualified staff. Notarianni et al (2009) highlights that to ensure maximum utilisation of facilities time should be allocated to train staff with time to develop and test scenarios. The involvement of multi-disciplinary teams is required to authenticate the simulated environment in the long term. Shared facilities for ongoing education as well as early student learning is most effective with clinical/industry partners. This not only amortises costs but increases the learning experience of all participants. Notarianni et al (2009) offers an example of a partnership, in Monarch General Hospital (MGH) who in 1999 implemented an acute care virtual facility at Old Dominion University with first year nursing students.
This framework establishes the opportunity for evaluation PPDM scenarios to see whether the designs meet the outcome objectives including addressing cognitive, affective, and psychomotor domains. Conclusions from the synthesis of literature in this paper did not provide evaluation or measurements of the effectiveness of outcomes related to linking theory to practice, clinical reasoning or the acquisition or retention of skills. However with further evaluation of PPDM, this framework may become the benchmark for acquisition of skills and knowledge required by both the nursing profession.
Conclusion: A combination of simulation training and a relevant educational framework offers a significant alternative over traditional teaching methods in preparing nurses’ for practice. The research suggests that simulation is beneficial in nursing education when used appropriately by allowing students to decide on the appropriate treatment and actions to care for a simulated patient, the experience allows them to learn from mistakes and act on their own judgement. Most importantly simulation allows student nurses exposure to more acute situations and conditions in a safe supported learning environment.
The research further indicates that simulation training and relevant educational framework is highly beneficial for learners of all disciplines however the success depends on the preparation of the environment and suitably qualified educators to guide the learners to a positive learning experience. However to enable simulation to be an integral part of the nursing/medical curriculum there is a need for more research and studies to address the issues of transferability to clinical practice, the importance of retention of skills over time and how simulation can address this ongoing issue.
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