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High-fidelity patient simulation in nursing education: an integrative review.

ABSTRACT An integrative review was undertaken to analyze studies published since 1998 on the use of high-fidelity patient simulation (HFPS) in undergraduate nursing education. This review found that HFPS benefits nursing students in terms of knowledge, value, realism, and learner satisfaction; findings were mixed in the areas of student confidence, knowledge transfer, and stress. Further research in these and other areas will determine whether its increased use is warranted.


HIGH-FIDELITY PATIENT SIMULATION (HFPS)--the use of realistic, simulated patients and clinical environments in the education of health care professionals--is more visible in nursing education than ever before (Jeffries, 2009; Nehring & Lashley, 2010). This presents a challenge to nursing faculty: can they justify the investment of time and money necessary to train faculty in the use of HFPS and incorporate the technology into their curricula? To answer that question, it is necessary to examine the effect of HFPS on nursing students.

HFPS provides opportunities for interactive learning that can be used in any nursing course. It can also be used as reinforcement for traditional classroom lessons and as an adjunct to laboratory sessions. Because competition among nursing programs for clinical sites can limit students' time in clinical rotations, HFPS has also been used as a supplement to those rotations (McCallum, 2007; Nehring, 2008). In a landmark study, the National League for Nursing (NLN) conducted a four-phase, national, multisite, multimethod project to design and implement models for simulation use in nursing education (Jeffries & Rizzolo, 2006). Several tools were developed and tested in this study. Its publication resulted in the development of a simulation model and a much-needed upsurge of interest in the use of HFPS in nursing education.

But does the evidence support HFPS as an alternative to clinical experience with real patients? This integrative review evaluates the findings of recently published research.

Hands-On Learning, Real-Time Decision-Making Simulation makes for an ideal learning environment for nursing students: it mirrors the clinical setting and mimics patients' responses in a controlled setting, without the risk of students harming patients. Unpredictable patient conditions can be included, as can the "patient's" responses to students' interventions. The theory is that HFPS can encourage students to push the limits of their abilities so that they can better learn what to do in a real clinical situation. Also, HFPS allows for the repetitive teaching of skills and concepts in a variety of clinical situations (Nehring, Ellis, & Lashley, 2001) and can be useful for students in need of remediation. It can also provide a learning opportunity for conditions that students may rarely encounter in a clinical setting.

HFPS can be used across the nursing curriculum. In beginning courses, for example, it can be used to teach fundamental assessment skills by demonstrating abnormal physical findings (Nehring et al., 2001). In medical-surgical nursing courses, it can be used to teach students about drug and IV fluid administration. The complexity of the content can be altered according to the care setting, such as geriatrics, pediatrics, obstetrics, and psychiatric nursing. HFPS can also be employed as part of an exit exam from a nursing program to demonstrate students' knowledge.

The future of educating health care professionals, including nurses, will be challenging. The 2010 Institute of Medicine (IOM) consensus report, The Future of Nursing: Leading Change, Advancing Health, recommends that 80 percent of all nurses have a bachelor's degree by 2020, a goal that it says will be achievable through the use of technology, including simulation, in nursing education (IOM, 2010). Further, licensing or accrediting entities might use simulation to evaluate competency. The IOM report To Err Is Human: Building a Safer Health System called on health care organizations and teaching institutions to develop and use simulation to train novice practitioners as part of an effort to reduce medical errors (Kohn, Corrigan, & Donaldson, 2000). If public pressure to reduce errors becomes strong enough, the federal government could set forth regulations requiring the use of simulation in the education of health care professionals (Gaba, 2004).

Method A systematic literature search was conducted using the following databases: Cumulative Index of Nursing and Allied Health Literature (CINAHL), Educational Resources Information Center (ERIC), Dissertation Abstracts, PubMed, and Google Scholar. A search with the phrase patient simulation produced results that were too broad, and so Boolean searching with the term AND was performed for the remaining searches. A search using high-fidelity patient simulation AND nursing education produced results that were too narrow; the most pertinent results came from a search using patient simulation AND nursing education. The search was done until an overlap in the articles was observed.

All of the articles found through the patient simulation AND nursing education search and the high-fidelity patient simulation AND nursing education search were hand reviewed. Also conducted was an ancestry search --reading article titles in the reference lists of articles obtained in the database searches--to determine whether other articles might be relevant. Careful attention was paid to terminology because authors use various terms when referring to HFPS.

Hand searches explored all literature from 1998 to April 2008. The year 1998 was chosen because Nehring et al. (2001) reported that, at the time, only one article had been published (in 1998) about the use of HFPS in undergraduate nursing education. Information found before that date focused on low- and medium-fidelity simulation.

INCLUSION AND EXCLUSION CRITERIA A priori inclusion criteria for the search included HFPS in nursing education and quantitative studies. Initially, only articles involving baccalaureate nursing programs were included in the search, but later articles on associate degree and diploma programs were included. The concepts of confidence and knowledge as they related to HFPS were used for the initial screening of the literature. After initial review and analysis of the articles, it became clear that several other concepts were worth examining: value, realism, stress, and knowledge transfer. All articles were reviewed again to determine whether they addressed these concepts. A concept that emerged in the new search was learner satisfaction.

Excluded were articles on HFPS used for the education, training, or orientation of nurses rather than nursing students, as were those limited to live patient simulation, computer simulation, and low-fidelity simulation; conference proceedings; and articles on the use of HFPS in graduate-level nursing education. No specific criteria were set for sample size.

High-fidelity patient simulation refers to predeveloped patient scenarios utilizing computerized manikins that respond to intervention by providing instant feedback. Since fidelity refers to the realism of the simulation, high-fidelity patient simulation is currently the highest level of realism offered with patient simulation. Low-fidelity patient simulation refers to individual manikin parts that are used simply as task trainers to teach students specific psychomotor skills. Medium (or intermediate)-fidelity patient simulation uses manikins that can be somewhat computerized; these offer opportunities to practice specific psychomotor skills but lack the complexity and realism of patient scenarios.

TERMINOLOGY The term patient simulation has been used throughout the nursing literature with a variety of meanings. In earlier literature, patient simulation referred to anything from people acting the role of an ill patient to computer software simulation to low- and medium-fidelity simulators. Most recently, the term has been used interchangeably with high-fidelity patient simulation. Another term used interchangeably with high-fidelity patient simulation is human patient simulation; many of the studies in this review used this last term.

It is interesting to note that although all of the studies in this review utilized HFPS, many of the studies did not use the term high-fidelity patient simulation, or another simulation term was used in the title. One study referred to intermediate-fidelity simulation in the title (Alinier, Hunt, Gordon, & Harwood, 2006), but the researchers' description of the study suggests that HFPS was used. For the purpose of this review, patient simulation refers to high-fidelity patient simulation conducted using realistic scenarios with a high-fidelity manikin.

Results and Review Process The search using the term patient simulation yielded 323 articles in CINAHL; 1,366 articles in PubMed; and 214 articles in ERIC. A search using the terms patient simulation AND nursing education yielded 36 articles in CINAHL; 117 articles in PubMed; and 23 articles in ERIC. Of these, five articles met inclusion criteria. The final search of the terms high-fidelity patient simulation AND nursing education yielded five articles in CINAHL; 19 articles in PubMed; and no articles in ERIC.A total of four articles from this search were used in this integrative review.

The remaining articles used were obtained through the ancestry search. The search in Dissertation Abstracts yielded one article that was included in the integrative review. The other dissertation used was found in Google Scholar. An updated search of the literature was conducted in November 2010 using all of the aforementioned methods. This update yielded six additional articles for use in this review.

A total of 24 articles were reviewed. The data from the articles were placed in a matrix constructed in Microsoft Excel. The matrix was examined for various concepts related to HFPS. These concepts were coded and listed in a chart for further synthesis. The concepts that emerged from the literature include confidence, knowledge, knowledge transfer, value, realism, stress, and learner satisfaction.

Google Scholar was also explored. The only articles found that were not in any of the other database searches were a dissertation and articles in Clinical Simulation in Nursing. Review of abstracts in this journal on the International Nursing Association for Clinical Simulation and Learning (INACSL) website revealed a potential eight articles. It is interesting to note that access to these articles was limited to members of INACSL and did not show up in any database search. Since the initial review of literature, this journal has been made available to nonmembers and can be found in database searches. There may be studies that are unpublished due to the recent interest and proliferation of HFPS.

Discussion Many of the concepts that emerged from this review touched on the effects of HFPS on confidence and knowledge. Others included knowledge transfer, value, realism, and stress.

C0NFIDENCE Many of the articles discussed the use of HFPS in providing a safe environment for students to make mistakes. However, findings on confidence were mixed, despite the fact that HFPS is frequently touted as increasing students' confidence. Johnson, Zerwic, and Theis (1999) reported that as students familiarized themselves with clinical situations, their confidence in handling such situations increased.

Abdo and Ravert (2006) reported an increase in students' confidence after their HFPS experience. In studies by both Bearnson and Wiker (2005) and Burns, O'Donnell, and Artman (2010), students reported that confidence in their skills increased after HFPS. Results from Kuznar's study (2007) showed that students believed HFPS improved their confidence. Smith and Roehrs (2009) found that students were self-confident based on their HFPS experience. Further, they reported that design characteristics of the HFPS, specifically, clear objectives and a challenging experience, significantly correlated with satisfaction and self-confidence. In the 2006 NLN study, students exposed to HFPS reported greater confidence in their ability to care for the type of patient used in the simulation than students not exposed (Jeffries & Rizzolo, 2006). Conversely, Feingold, Calaluce, and Kallen (2004) found that a majority of students did not perceive HFPS as increasing their confidence. In other studies, there was no significant difference in confidence between students who participated in HFPS and students who did not participate (Alinier, Hunt, & Gordon, 2004; Alinier et al., 2006; Blum, Borglund, & Parcells, 2010).

When there is a reported increase in confidence after HFPS that is not then measured in a clinical setting, the student may perceive an increase in confidence due to being in a controlled, supervised setting where he or she can do no harm (Rockstraw, 2006). Perhaps the increase of confidence is not realized until the student experiences a real situation like the one in the simulation. There is little research that examined whether confidence gained in HFPS was transferred to the clinical setting. The student reporting an increase in confidence after HFPS only is speculating; will confidence and knowledge gained during a simulation apply to the clinical arena? More research about the transferability of the simulation experience into the clinical setting, specifically regarding confidence, is needed.

KNOWLEDGE Overall, students reported an increase in knowledge after the HFPS experience (Alinier et al., 2004; Radhakrishnan, Roche, & Cunningham, 2007). One study showed that HFPS used as a substitute for one day of clinical experience with third-year nursing students increased their knowledge of medication effects and responses (Bearnson & Wiker, 2005). Another study indicated that when HFPS was used in addition to traditional lectures with first-year nursing students, most "showed a significant gain in knowledge" (Burns et al., 2010).

Dillard et al. (2009) examined students' perceptions of the degree they felt they understood the learning objectives of a HFPS. Students indicated that they either "mostly got the concept" or "totally got the concept" of all the learning objectives for the simulation.

Hoffman, O'Donnell, and Kim (2007) used the Basic Knowledge Assessment Tool-6 to measure improvement of knowledge in senior nursing students after seven weeks of HFPS and seven weeks of a traditional clinical experience. They found significantly improved scores in six of eight subscales; the two subscales that did not show significant improvement assessed issues not addressed in the HFPS. More research that compares knowledge gained in traditional clinical settings and simulated settings is needed.

Schumacher (2004) measured learning outcomes and critical-thinking abilities in junior nursing students using a customized Health Education Systems, Inc. exam. This study revealed a significant increase in knowledge and critical thinking when simulation or a combination of simulation and classroom instruction were used. Two studies did not find that knowledge increased after use of HFPS, however. Kardong-Edgren, Anderson, & Michaels (2007) divided 14 students into three groups--lecture only, lecture and low-fidelity patient simulation, and lecture and HFPS--and found no significant difference in students' posttest scores. Limitations included a small sample size, the use of a convenience sample, and simulation not being examined apart from lecture. Also, Schlairet and Pollock (2010) found no difference in knowledge acquisition among 74 students exposed to a traditional clinical experience and HFPS.

KNOWLEDGE TRANSFER Several studies examining the transfer of knowledge gained from HFPS into the clinical setting had mixed results. Abdo and Ravert (2006) found that 100 percent of the students believed that their HFPS experience would benefit them in the clinical setting. Conversely, another study showed that slightly less than half of the students in the study thought that knowledge gained in HFPS would transfer to the clinical setting (Feingold et al., 2004).

VALUE Students' perceptions of the value of HFPS were measured in several studies. Abdo and Ravert (2006) found that 95 percent of students found it valuable, especially as it related to clinical decisionmaking. Feingold et al. (2004) reported that a majority of students found HFPS to be a valuable learning tool. The majority of students in a study by Wotton, Davis, Button, and Kelton (2010) felt that simulation showed the usefulness of what they were learning and viewed debriefing as an important component of HFPS.

REALISM Realism in HFPS was studied from various angles. Ninety-six percent of students in Abdo and Ravert's study (2006) about students' perceptions of HFPS agreed that the simulation was realistic and that it recreated real-life patient situations. The majority of the students who commented on realism in the 2006 study by Bremner, Aduddell, Bennet, and VanGeest and the 2004 study by Feingold et al. thought the HFPS experience was realistic.

Several studies examined students' perceptions of the importance of realism. Students in the NLN study (Jeffries & Rizzolo, 2006) rated realism as one of the most important features of HFPS. Also in that study, students who participated in HFPS said that the experience was more realistic than did students in groups that used simulation with a case study or a static manikin. In a mixed-methods study by Cantrell, Meakim, and Cash (2008), students placed high importance on the realism of the simulation as a learning experience.

STRESS Several studies examining the stress levels of students working in a simulated environment produced inconsistent results. In a British study, Alinier et al. (2004) found that there was no difference in perceived stress between two groups of students; one group had one exposure to HFPS, and the other had two exposures. In a later study (Alinier et al., 2006), these researchers again demonstrated no difference between the groups. The second study included 99 students in the sample; the earlier study had 67 students.

Bremner et al. (2006) found that fewer than half of the students in their study said that HFPS relieved some of the stress on their first clinical day. Students in Morrison and Catanzaro's study (2010) reported feeling overwhelmed and anxious about how to respond during a simulated public-health emergency.

OTHER ISSUES Schools of nursing are beginning to investigate issues of patient safety using simulation. Gantt and Webb-Corbett (2010) reported that during simulation, students did not satisfactorily perform hand hygiene or patient identification 61 percent of the time and only 38 percent of the time after instruction. Missing from the literature, perhaps because HFPS has not been used long enough for all outcomes to be measured, are studies on the transfer of knowledge from HFPS after graduation, the effectiveness of teaching strategies such as debriefing and videotaping during the use of HFPS, and the cost-effectiveness of HFPS in nursing education.

One study examined student satisfaction with HFPS according to learning style. Fountain and Alfred (2009) found that students who were identified as having social and solitary learning styles were significantly correlated with satisfaction with learning during HFPS. Student satisfaction was reported after a HFPS and significantly correlated to both learning objectives and an appropriately challenging simulation (Smith & Roehrs, 2009).

Implications for Research It is evident that more study on HFPS in nursing education is needed, especially in the areas of communication among participants in simulation, feedback and support given during and after simulation, and student satisfaction. Also, continued research efforts are needed in the following areas:

* New theories and models for HFPS

* The cost-effectiveness of various types of fidelity in simulation

* Students' knowledge acquisition through HFPS, as compared with traditional clinical experience

* The stress of working in simulated clinical environments, as compared with real clinical settings

* The transfer of knowledge when students become new nurses

* The effect of various teaching strategies involved with HFPS, including debriefing and videotaping

* Students' confidence in clinical experiences after being exposed to HFPS

* The quality of debriefing after HFPS

* The effectiveness of HFPS on students' clinical judgment

Conclusion This review of the literature found that HFPS benefits nursing students in terms of knowledge, value, and realism. Further research will determine whether its increased use is warranted, especially in terms of whether benefits outweigh costs. But because nurses must be prepared to work in an exceedingly complex care environment, nursing students must be educated with the most realistic technologies available. HFPS might just change the face of nursing education.


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Amy Weaver, MSN, RN, ACNS-BC, an instructor in the Department of Nursing at Youngstown State University, Youngstown, Ohio, is a doctoral candidate in the Villanova University PhD in Nursing Program. Contact her at
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Author:Weaver, Amy
Publication:Nursing Education Perspectives
Date:Jan 1, 2011
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