Recent trends in simulation use have necessitated a more considered approach in the use of this teaching/learning tool. The aim of this research is to discover ways to improve simulation as a teaching/learning platform. Action research was used to answer the question, “How can I improve pedagogical practices with undergraduate nurses in simulation?” This study was implemented at a University in Auckland, New Zealand between November 2012 and March 2014. A purposive sample was sought from second and third-year nursing students (n = 161) enrolled in the three-year undergraduate bachelor of nursing program. Methods included focus groups, questionnaires, debriefing sessions, pre- and post-tests, and Lasater clinical judgment rubric analysis. Seven instructional scaffolds emerged which maximized student learning and retention. These scaffolds: 1) helped move students from known into unknown knowledge; 2) provided situated coaching; 3) modeled expected performance; 4) gave opportunity for improvement; 5) reduced confusion; 6) taught effective communication; and 7) promoted new learning through debriefing. These strategies resulted in a simulation experience which improved clinical reasoning in undergraduate nursing students.
Simulation as a teaching tool has been used in nursing education for over 100 years [
This research emerged out of a need to understand how educational philosophy impacts simulation design, and how to best apply educational scaffolds to support student learning [
Developing a simulation program involves more than purchasing a manikin [
In education, scaffolding refers to a variety of instructional techniques used to move students progressively toward deeper understanding and, ultimately, greater independence in the learning process [
1) Conceptual scaffold: Cues or hints which help students to reach a solution;
2) Coaching scaffold: Direct teaching strategies or heuristics;
3) Feedback scaffold: Providing progressive feedback while the task is being undertaken;
4) Reflective scaffold: Encouraging reflection on tasks by asking the student to self-monitor their approach; and
5) Modeling scaffold: Providing an example or demonstration of expected performance.
Simulation, as a teaching tool, encourages more active participation and interaction among students because students “do not just watch the simulation, they are the simulation” [
Participant rights in this research were protected and subject to institutional review board approval. Following ethics approval, this study employed action research with the intention of developing a living theory [
This study was implemented at a university in Auckland, New Zealand between December 2012 and April, 2014. Interpretation of data was informed by the writings of John Dewey [
Cycle One involved two focus groups which explored the current context of simulation in undergraduate nursing [
Original sentence examples | Free Node (Code) | Tree Node (Category) | Theme |
---|---|---|---|
What I really hate about the simulation is the glass. I’d love the educator to be down on the floor with us. | Anxiety-producing | Supportive learning environment | Situated teaching in room by facilitator |
Being in the simulation knocked my confidence. When you’re running around like headless chickens you think, “When this does happen in the hospital, am I going to know what to do?” | Anxiety producing (decreased confidence) | Supportive learning environment | Facilitator training in debriefing |
I do not think we have enough opportunities. We should be doing one a week. | Practice | Simulation opportunities | Scaffolded simulation program |
Knowing at the beginning what is expected of us would have been helpful, rather than being chucked as a group into the room. They just start the simulation and we wonder what it is we should be doing. | Lack of orientation | Simulation design | Sound pedagogical underpinnings in design |
If we go from the parenting thing, we know the educators can ride a bike. We need to have the training wheels on at first until we can gain the confidence to take the training wheels off. | Practice | Simulation opportunities | Scaffolded simulation program |
Cycle two embedded student suggestions made in cycle one. This cycle involved second year students who participated in the newly designed scenario which employed pre- and post-questionnaires to determine the most valued instructional elements. The following changes were made to the simulation:
・ More time was allotted (1.5 hours) for the simulation and debriefing.
・ Students were oriented to the simulation room before scenario.
・ Pre-briefing to the simulation was given.
・ Educator came out from behind the one-way glass and stayed in the room.
・ Students were allocated one of four roles.
In Cycle Two, students completed a pre- and post-simulation questionnaire [
Cycle Three involved students moving through a simulation suite of three scenarios (hypovolaemic shock, croup, acute coronary syndrome) [
The students’ second performance in each scenario was analyzed by two educators using the Lasater Clinical Judgment Rubric [
Recruitment methods for this research varied within each cycle. Cycle one recruited participants via student university email and involved students from all three years of an undergraduate nursing program (n = 15). Cycle two recruited volunteers via an intermediary in the second year of the nursing program (n = 125). Cycle Three employed recruitment via university email to final semester nursing students which quickly expanded to snowballing as students began to recruit through a student-operated FacebookTM page (n = 21).
Sample size involved no power calculation and was dependent upon student availability and snowballing (cycle three). Participants were all between the ages of 18 and 32 years at the time of this research. Four participants were male, the remainder female. All participants were enrolled in a three-year bachelor of nursing program in Auckland, New Zealand. Participants were 54% European, 22% Asian, 9% Pasifika, 6% Maori, and 9% undeclared.
Confidentiality was maintained by way of using aggregated data and/or pseudonyms. Informed consent was obtained after reading the prepared information sheets. Participants consented to being photographed and videoed during all three cycles of this project. Researchers stressed throughout that no judgements of educational or clinical practice were being made and that decisions regarding participation would not affect future education or employment.
Themes emerging from thematic analysis [
“I feel sick on the days I have to go into the SIM room―literally sick. No confidence. I feel awkward the whole time. It is too quick, and the situations are complex which isn’t really necessary (Focus Group 1, Cycle One)”.
Students desired to be gently moved through the simulation instead of being exposed to what felt like an out-of-control situation. The need for stated learning outcomes was voiced in the following comment:
“Going over it [the learning outcomes] before the simulation helped us. We could check the BP and make sure we could hear everything, and review how to do the nebulizer. The devil is often in the details in an arrest and it’s those little things that can trip you up (Debriefing, Cycle One)”.
The need for educator training in the facilitation of simulation was voiced by the following student:
“We need to have the training wheels at first until we can gain the confidence to take the training wheels off. It would be better to say, ‘Keep the wheels on until you can go to the end of the driveway by yourself’. When I was learning to ride a bike, my dad would run beside me and say, ‘You’re going to fast!’ I need the lecturers to do the same thing (Focus Group, Cycle One)”.
This comment, along with many others, expressed the need for educator training in simulation design and facilitation. We had the equipment, but we now needed the training in order to build an effective undergraduate simulation program.
Cycle two yielded a prioritization of instructional scaffolds which were valued by students and contributed to their learning. The four most valued educational components of the revised simulation were: 1) educator modeling of expected simulation performance; 2) opportunity to repeat simulation after feedback given; 3) supportive debriefing after simulation; and 4) using the ISBAR tool to obtain support from other professionals.
In regards to modeling of expected performance, one student stated:
“The role play that [the educator] did in the middle was really helpful to show us all of the roles needed and assessments that needed to be done (Questionnaire, Cycle Two)”.
In regards to repetition, the comment was made:
“[Repetition] helped immensely. It gave me an opportunity to ‘right what was wrong’. Being told what went wrong, and then leaving it at that is not enough for me to know that I have learnt it properly. (Questionnaire, Cycle Two)”.
Supportive debriefing during and after the simulation was voiced as follows:
“In the past, the lecturers needed to have a more positive attitude when giving feedback [debriefing]. Historically we had lecturers who ‘told us off’ for the negative aspects of practice with no emphasis on even a tiny bit of positive aspects of our practice (Questionnaire, Cycle Two)”.
The simulation employed in Cycle Two involved a deteriorating situation in which students were required to recruit assistance of other professionals using the ISBAR tool (Identify, Situation, Behavior, Assessment, Requirement). The use of the ISBAR tool was identified as the fourth most valued educational component in the simulation. One student stated:
“I feel more confident as I now know effective communication skills [through ISBAR]. I mostly appreciated learning that in a live situation we must be fully prepared before calling doctors as being hung up on in reality would be extremely humiliating (Questionnaire, Cycle Two)”.
Communication is key to management of safe patient care. Ultimately, Cycle Two students requested a simulation suite be available in their final semester in order to prepare for entry to professional practice. Thus, Cycle Three emerged.
Cycle Three provided some insight as to the effect of simulation on content knowledge. As can be seen in
“I liked the pre- and post-test because I could see my improvement. It makes you aware of what you do not know also (Focus Group, Cycle Three)”.
An interesting aspect from the pre- and post-test data involved a measure of variability called the standard deviation (SD). Standard deviation is a descriptive statistic which indicates the variation from the average [
The standard deviation for the three scenario test results were 1) hypovolaemic shock SD = 1.94; 2) croup SD = 1.63; and 3) acute coronary syndrome SD = 1.23. The standard deviation decreased as the students progressed through the scenarios. This indicates that the students were showing progression in their ability to master the subject matter. This improvement in content knowledge was echoed in the focus groups:
“Seeing the progress is what is satisfying to us. Seeing ourselves get better really satisfies us personally. Because we know we can improve (Focus Group, Cycle Three)”.
The students also commented on the powerful influence of modeling on their learning:
“With the pediatric simulation I noticed when [my partner] and I did the simulation first time we went for the IM injection first. When we watched the model clip we noticed the educator did the nebulizer first. That made sense as it [the adrenaline nebulizer] acts faster in the lungs than the IM injection. So we changed that order of medications for our second attempt because that made sense (Focus Group, Cycle Three)”.
・ Hypovolaemic shock: Average improvement of 1.2 points between tests
・ Croup: Average improvement of 2.9 points between tests
・ Acute coronary syndrome: Average improvement of 2.3 points between tests
Research has shown that it is possible to enhance performance by warming students up to tasks in the educational environment [
By the time the students had completed two scenarios (one hour each), it is possible fatigue began to influence their performance in the final scenario. Research has shown that with progressive multiple choice testing, there is a point where fatigue or boredom can influence test results in the opposite direction, and thus increase the variance and errors in test results [
Cycle three employed the Lasater rubric [
When asked about the effects of simulation on her overall performance as a nurse, one student summed it up stating:
“…just being able to hold a space in an emergency situation has improved. Even my knowledge and interventions grew and we learned more as we progressed (Focus Group, Cycle Three)”.
This renewed confidence coupled with an improved ability to manage deteriorating situations was keenly felt by students participating in the simulation suite.
Simulation of real-world settings in which students construct knowledge through active participation in learning increases student engagement [
management strategies. Seven scaffolds emerged from this research which helped guide students as they constructed their own learning in the management of deteriorating clinical situations.
In order to gently introduce students to the scenario, a pre- and post-simulation test were employed. The test was designed to highlight what the student knew about the causes and contributing factors of the particular deteriorating situation they would encounter in the simulation. The causes of the deterioration were outlined in the pre-briefing (a video podcast of 7 minutes) [
The pre- and post-tests were a form of conceptual scaffolding in that they hinted to ways students might reach a solution in managing the “storm”. Because the tests were administered before and after the simulation, they were also a form of feedback given within the simulation learning package (feedback scaffold). In nearly every case, post-tests showed improved scores over pre-tests (
Simulation should engage the student’s activities in a way which is at once both enjoyable, and at the same time inspires future learning. Dewey ( [
Students in the focus groups in cycle one shared that simulation educators “behind the one-way glass” unnerved them, and created a sense of competition between students and educators which destroyed their sense of a supportive learning environment. This strategy of working alongside students during the simulation provides progressive feedback while the task is being undertaken [
John Dewey ( [
Some [
Students in the second action cycle rated modeling by the educator as the most valuable aspect influencing their performance in the simulation. According to McLoughlin [
Dewey [
Students in cycle two stated that the second most valued aspect of the simulation was the allowance of a repeat performance. Allowing for repeat performance, after feedback is given, is a form of conceptual scaffolding [
Repetition is a valuable aspect of behaviorist and cognitivist philosophical thought [
Students in all three action cycles stated that creating roles helped them to manage clinical deterioration with greater efficiency and confidence. Designing the simulation so students perform within a role is a conceptual scaffold [
Additionally, roles help to reduce cognitive load, the amount of processing required to integrate new information by the working memory [
The use of the ISBAR (Identify, Situation, Background, Assessment, Requirement) tool was the fourth most valued interventional scaffold identified by students. Teaching the use of this tool is a coaching scaffold [
These comments are aligned with the importance of clear and concise communication shown in the literature [
Debriefing is a reflective scaffold [
Dewey [
These instructional events are categorized into scaffold types in
This study was limited by the number of participants involved. Small numbers in the third action cycle constrained generalizability. In order to make appropriate applications to practice, further research could use a similar design to the third action cycle with approximately 100 students in each scenario (acute coronary syndrome, croup, hypovolemic shock).
Another limitation in the study was a lack of training for raters in the Lasater Clinical Simulation Rubric. Due to time constraints, the raters were not upskilled resulting in compromised interrater reliability. This could be amended by training all raters in the use of the Lasater rubric before data collection. Taking this extra step would improve the internal validity of the study.
In this research, seven scaffolds were employed to help students manage a simulated deteriorating patient situation. Clinical deterioration in patients is similar
Instructional event | Scaffold used | Purpose of Scaffold |
---|---|---|
Pre- and post-simulation tests | Conceptual & Feedback Scaffold | To assist students in understanding the basic causes, signs, symptoms, and treatment of a deteriorating patient condition |
Work alongside in situated coaching | Coaching & Feedback Scaffolds | To improve problem-solving and enhance critical thinking |
Model expected performance | Modeling & Reflective Scaffolds | To provide an example of expected performance while allowing students to reflect and modify their own performance |
Give opportunities for improvement | Conceptual & Reflective Scaffolds | To encourage student self-monitoring with a mind to improve overall performance while improving patient outcomes |
Allocate roles | Conceptual Scaffold | To assist students to perfect one role while reaching final goal of saving patient and working effectively within a team |
Teach effective communication (ISBAR) | Coaching Scaffold | To allow students to call for assistance in a deteriorating patient situation |
Debriefing | Reflective and Feedback Scaffolds | To encourage students to self-monitor and self-assess while improving overall performance |
to navigating a “storm on the open seas”. As on the seas, the ultimate end of poor patient management could be severe loss or even death. The seven scaffolds highlighted in this research are in actuality seven instructional interventions. In summary, the seven scaffolds are: 1) understanding basic causes of the storm; 2) providing course correction in the midst of the storm; 3) modeling best practice in managing the storm; 4) perfecting new skills for navigating the storm; 5) giving every sailor a role in the midst of the storm; 6) calling for help to ensure survival of the storm; and 7) reflecting on how to better manage the next storm.
None of this is hard. Nevertheless, at the nursing school where this research was conducted, these scaffolds were not being enacted prior to the work done in this research. They are simple strategies that underpin a learning experience that excites, engages and grows the confidence and competence of students.
Erlam, G.D., Smythe, L. and Wright-St Clair, V.A. (2017) Navigating the Storm of Deteriorating Patients: Seven Scaffolds for Simulation Design. Open Journal of Nursing, 7, 683-697. https://doi.org/10.4236/ojn.2017.76051