Simulation in Nursing Education
The concept of simulation in healthcare education has been since the time of world II. The basic concepts of simulation in associate’s or bachelor’s nursing program comprised of CPR manikins, role playing, static manikins, and conventional techniques based on the utilization of various taught concepts were used as a teaching modality since over 5 decades (Norman J. 2012). The concept of high-fidelity education has been in place for over 2 decades but it is new and unique in the nursing education. The process involves the use of simulation with the help of high-end computer technology including simulation monitors and computers (Motola, et al. 2013). The process of learning is based on teaching nursing students of real-life case scenarios which would involve critical and logical reasoning coupled with live experience and practice (Norman J. 2012). There is limited evidence on the outcome research on the use of simulation on associate’s or bachelor’s level nursing program. Researchers have stipulated that simulation is the next-level educational platform in the nursing profession which would be completely implemented by 2035 (Motola, et al. 2013). This article focuses on the qualitative and quantitative areas of research with respect to simulation in nursing education programs.
Based on a few research concepts on simulation, researchers state that simulate is referred to ‘act like or to look like.’ Researchers also state that the simulation would not only include mechanical platforms but would also include case studies, scenario-based clinical thinking, role playing, and a few conventional platforms associated with simulation (Norman J. 2012). Based on the current information, it can be understood that simulation has been practiced in nursing education since a long time which may include examples such as using oranges to practice intramuscular and subcutaneous injections, role playing major mental disorders, inserting foley catheters in a manikin in a lab setting, learning CPR on a static manikin or maybe improving communication skills in mental health (Chiniara, et al. 2013). Most of the activities are some form of simulation with a common concept which relates to an artificial and controlled environment for students to learn and rationalize real case scenarios during practice (Norman J. 2012). Based on a few current and conventional research papers, the first documented use of high-end simulators was based on pilots in the early 1930’s (Chiniara, et al. 2013). The concept of simulation among pilots still continues with respect to engine failures, loss of power, or poor weather conditions. The concept of simulators was introduced in order to enhance safety protocols in pilot training. Based on these safety protocols and concepts of simulated learning, the Institute of Medicine introduced the same within the nursing faculty (Motola, et al. 2013). Based on a similar study that reported the need for simulation in nursing education, revealed that patient safety was a priority among nurses dealing with emergency care and epidemic situations. (Liaw, et al. 2012). Simulation in nursing programs can help nurses prepare and nurture skills and values in mock disasters that would include other professionals such as physicians, paramedics, firefighter, police, and military. Simulated mock drills help nurses to be aware and mentally prepared for community-based natural disasters (Norman J. 2012). The study provided a valuable insight on the need for simulation in nursing in order to provide high quality healthcare services and also improvise on the current healthcare delivery systems.
Based on a recent study, the shortage of nursing staff has resulted in the development of a diverse group of nurses interested in various setting of the healthcare system (Berragan. 2011). In the high demand for nursing professional, nursing education faces a shortage of teaching faculty. There is an increase in demand for high-level knowledge exploration in the professional arena of nursing (Liaw, et al. 2012). Based on a systematic review, researchers provided the 4 dimensions of clinical judgement based on teaching experience which were as follows: (a) Self-report on clinical judgement analysis and skills (b) Aptitude for critical and logical thinking (c) Simulation-based qualitative observation and clinical judgement skills and (d) Focus group-based clinical reasoning and student’s experience. (Norman J. 2012). This paper provides an overview on the use of simulation in nursing education programs.
Evidence supporting the benefits and advantages of simulation in Nursing Education
Simulation has been the forefront of nursing education programs. The concept of simulation has been associated with improved clinical outcomes, decreased burden on teaching faculty, enhanced learning experience, student satisfaction, and reduced medical errors (Liaw, et al. 2012). Based on a recent study, simulated modules were developed for Bachelor of Nursing students. The simulation modules provided an enhanced learning experience to students. The key focus of the modules were based on again care practice (Harrison & Andersen 2016). The modules were based on the prevention, treatment, and management of elderly patients based in various healthcare settings (Garrett, 2013). The process of bonding, communication, treatment intervention, and medical management of elderly patients were taught in a simulated and artificial environment. The simulations comprised of videos and audio books based on medication reminder, risk of falls, psychological counselling, peer group interaction, and mind-body techniques to improve overall health outcomes. The concept of simulation for aging process is a unique platform to be explored (Harrison & Andersen 2016).
Simulation learning has been introduced in the orthopaedic arena of nursing due to increasing demand of post-surgical care in healthcare settings. The simulation modules comprises of various fractures, the critical diagnosis, surgical interventions, and the post-surgical management protocol (Pettersson, et al. 2008). Nearly 90% of nurses play a critical and demanding role in the management of patients in the post-operative care. The most important modules learnt in the simulation include caregiving process, post-surgical physiotherapy, exercise, or management, medication management, and handling patient feedback (Madhavanprabhakaran, et al. 2015). The most critical aspect of orthopaedic surgical care, is the requirement of pain assessment and management among patients. The simulation modules provide a comprehensive overview of various pain assessment tools (Liaw, et al. 2012).
Simulation nursing has also played a critical role in the development and management of various cross-platform learning interfaces in critical care and cardiology for nurses. In a recent study, researchers assessed the efficiency and effectiveness of simulation learning in cardiac surgery (Cato & Murray. 2010). Most nurses are unaware of the various treatment modalities (including surgical interventions and tools) used for basic cardiac surgery (Rauen. 2004). The purpose of developing a simulation module on cardiac surgery was to enhance and improving the learning experience of nurses involved in critical care with a focus in cardiac surgery (Valizadeh, et al. 2013). Most of the modules comprised on interactive videos based on the development of various surgical tools and apparatus used before, during, and after cardiac surgery (Cato & Murray. 2010). The modules also provided an insight in the post-management care of patients involved in cardiac surgery (Rauen. 2004). Real case-based scenarios were incorporated in the modules for critical and rationale thinking of nursing professionals enrolled in Bachelor’s program (Garrett, 2013). Since most nurses are not aware of computer-based simulation in critical care, simulation enhanced the learning experience of student nurses
In a recent study, a team of researchers from Norway assess the use of High-fidelity simulation in the second year of a 3 year bachelor of nursing program (Thidemann & Söderhamn O. 2013).The objective of the study was to assess the efficiency and effectiveness of simulation learning among nursing students. There were many sub-groups based on various simulations and nurse roles such as family member, caregiver, physician, or nurse (Abe, et al. 2013). The students were assessed based on 3 key factors which were self confidence in learning, student satisfaction, and knowledge (learning) gained throughout the simulation course. The simulation learning provide an overwhelming support and response by the students. Most of the students improved on their communication, collaborative, and practical skills (Thidemann & Söderhamn O. 2013). Thus, the inclusion of simulation courses enhances learning experience and increases health outcomes (Valizadeh, et al. 2013).
Evidence supporting the challenges & disadvantages of simulation in Nursing Education
Although simulation has been of significant importance in nursing education, it is widely criticized owing to high cost, maintenance, development time, learning ability, and individual differences (Summers & Kingsland 2009).Utilizing simulation is associated with high costs and relative fixed costs for development (Summers & Kingsland 2009). This can be a limitation for small organizations which have low funds and limited training budgets. Based on a recent survey, the average cost of developing an e-learning module would take 750-1,500 hours including one hour each for training (Buxton, Phillippi, Collins. 2015). In a similar study, researchers found mixed results on the effectiveness of simulation-based learning modules and training for nurses which is an essential challenge (Summers & Kingsland 2009). There is no evidence on the outcomes of simulation learning with overall advantage over conventional learning experience (Liaw, et al. 2012). This study suggests that there is further research required to assess the feasibility to develop and implement simulation based learning modules in nursing education programs. Furthermore, instructional designers have limited options and guidance to develop a comprehensive and effective learning platform (Summers & Kingsland 2009). Thus, due to feasibility issues and the lack of instructional design guidance and support, the simulation industry comprises a small portion of the e-learning industry in comparison to conventional learning and practical methods (Buxton, Phillippi, & Collins. 2015). In a quote stated by Ruben based on simulation based learning challenges, he states “As much as computers, the Internet, distance learning, and other new teaching and learning technologies and tools have great promise, they are clearly not panaceas.” (Khalaila. 2014).
Based on current evidence, most nursing students using simulated-based learning platforms face a series of difficulties and challenges in coping with learning and understanding various concepts of modules without the direction of a real trainer or teacher. (Summers & Kingsland 2009). The concept is termed as learner control challenges in simulated learning (Miller. 2010).
There is significant research based on the usability of simulation-based training that highlights the ineffective use and control of the platform by students (Miller. 2010). A few research studies also depict poor performance by students from simulated learning owing to poor decisions, early termination of study, poor effort to training, access to current knowledge, and ability to skip varying learning opportunities (Khalaila. 2014). It is important for students to develop an interest over simulated learning which is often not observed in the nursing fraternity (Miller. 2010). Based on a recent survey, simulations need to be addressed and do not work on their own; hence student structuring and motivation is required (Miller. 2010). However, a couple of studies have indicated that support from e-learning agents and adaptive advice can motivate students to continue using the simulated learning platform (Miller. 2010). There is limited evidence on the role of simulations in motivational and cultural learning by students. There is a need for a structured process and guidance for training (Liaw, et al. 2012).
Simulation based learning is also based on individual preferences and differences in coaching and understanding. Researchers state that key factors such as prior experience, differences in ability, and disposition play a confounding role in simulation based learning among nursing students (Miller. 2010). The ability of the students to interpret, approach, and respond to simulated training is also varied which is a profound challenge (Kelly, et al. 2016). Many observational studies have also voted the importance of individual differences in the adaptability of simulated learning (Miller. 2010). One of the most significant challenges and essential requirements that are missed in simulated learning include lack of peer competition on similar activities and pressure or presence of an instructor-based environment (Miller. 2010). The overall effectiveness of simulated learning is based on individual’s perception and understanding for technology-based platforms. Students with no or limited exposure to simulated learning may find it difficult and take longer to learn different concepts (Miller. 2010). Thus, simulated learning is associated with many challenges (Teixeira, et al. 2015).
Role of the Doctor of Nursing (DNP) in resolution of issues/conflicts associated with simulation in nursing education
The doctor of nursing plays a key role in the management of simulated learning which includes student participation, study efficiency, and effectiveness of the overall program. The role of the DNP in simulated education and training is complex and critical. Most DNPs play a diversified role in managing most issues and conflicts associated with simulated learning platforms (Aebersold & Tschannen D. 2013). The first role of the DNP is to ensure sufficient enrolment of students in the simulated nursing program. It is the duty of the DNP along with the teaching personnel to overview the process and rate of student enrolment in simulated learning (Teixeira, et al. 2015). The second major role in simulated learning in the nursing environment is conflict resolution and technology support/assistance. DNPs would coordinate with the entire support staff involved in the development of the simulated learning platform. Most nursing students would find it difficult to understand concepts of distance and virtual learning (McCaughey & Traynor 2010).
DNPs play a critical role in motivating and encouraging new students to engage in simulated learning. DNPs are involved in various communication strategies to engage and encourage students to participate and adhere to both, conventional and simulated learning (Cant & Cooper 2010). DNPs would setup a 24*7 support system that would provide assistance to students enrolled in nursing in the event of technical issues, virtual trainer, e-module backup, and learning assistance. (Aebersold & Tschannen D. 2013). DNPs would also act as lead in most of the simulated programs and act as a guide in group discussion portals available within the platform (McCaughey & Traynor 2010). Based on current evidence, DNPs are known to have a significant impact on conflict resolution and student enrolment in simulated learning platforms (Thidemann & Söderhamn 2013).
Summary
The concept of simulation in healthcare education has been since the time of world II. The basic concepts of simulation in nursing program comprised of CPR manikins, role playing, static manikins, and conventional techniques. Simulation has been the forefront of nursing education programs. The concept of simulation has been associated with improved clinical outcomes, decreased burden on teaching faculty, enhanced learning experience, student satisfaction, and reduced medical errors. Researchers provided the 4 dimensions of clinical judgement based on simulated teaching experience which were as follows: (a) Aptitude for critical and logical thinking (a) Self-report on clinical judgement analysis and skills (c) Simulation-based qualitative observation and clinical judgement skills and (d) Focus group-based clinical reasoning and student’s experience.
The major impacts and advantages of simulated learning in nursing education include (a) Improved nursing outcomes (b) Enhanced learning experience (c) Improved performance (including academic and professional) (d) Increased level of understanding (e) Improved communication, collaborative, and practice skills (f) Improved understanding of practical concepts and (g) Reduced medical errors (Harrison & Andersen 2016).
Although the stimulation-based learning platform has been highly recognized, many researchers have criticized the platform on the following terms: (a) Includes high cost (b) Long time for development (c) Fixed costs associated with development (d) Low learner control over the platform (e) Individual preferences and differences and (f) Mixed results on the overall outcomes of simulation versus conventional teaching methodologies (Summers & Kingsland 2009). Thus, it can be concluded that simulation based learning platforms have been recognized and recommended by most researchers in associate’s and bachelor’s level nursing program, it is advised to overview some to the key critical issues arising over simulation based platforms.
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