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Human simulators in nursing education.

Developments in computer technologies have thoroughly reformed nursing education (Saba & McCormick, 2006). Due to such developments, students who are now accustomed to using computers expect this tool to be incorporated into their education (Saba & McCormick, 2006). One exciting new technology is the field of human patient simulators (HPS), computerized life-sized mannequins that have the ability to formulate realistic case scenarios that can be altered rapidly to meet the instructors' educational goals. The purpose of this paper is to discuss historical perspectives of HPS, explore the capabilities and use of HPS, review studies to support the use of HPS in nursing education, discuss the effectiveness of the HPS in clinical simulations, and propose future uses for HPS.

Historical perspectives

Historically, the first HPS, 'Mrs. Chase,' was developed in the late 1950s (Herrmann, 1981). The model comprised a torso and separate computerized software. Mrs. Chase was used to help nursing students perfect their physical assessment skills. In the 1960s, the 'Harvey' model was created (Herrmann, 1981). This model contained a heart and lungs that helped students distinguish between normal and abnormal cardiopulmonary findings. The first fully-equipped computerized human simulator was Sim One, which was mainly used for endotracheal intubations in both medical and graduate nurse anesthesia programs (Gaba & DeAndra, 1988).

The HPS that are presently being utilized, for example MetiMan, Laerdal SimMan, and BabySim, come fully equipped with computer software and can be connected to laptop or desktop computers (Nehring, Lashley, & Ellis, 2002). The MetiMan and Laerdal SimMan high-fidelity HPS, each comprising a mouth and airway, are able to blink and speak, have chest walls that visibly expand on inspiration and relax on expiration, and generate audible lung and heart sounds that are programmable. These mannequins may be intubated, and receive bag and mask ventilation. When the device is connected to a monitor, an instructor can program cardiac rhythm, pulse oximetry reading, and both venous and arterial pressures (Sullivan-Mann, 2007; Peteani, 2004). These HPS can also be programmed to produce human-like responses to numerous disease states and reactions to treatments and interventions such as intravenous (IV) medication administration, intubation, ventilation, catheterization, and cardiopulmonary resuscitation.

Capabilities and uses of HPS

Desktop or laptop computers have been used in classrooms primarily to facilitate communication and the acquisition of knowledge (Saba & McCormick, 2006). Current applications now facilitate and support clinical learning as well.

Many colleges and universities have simulation centers that are open for students to practice and develop their basic technical skills, as well as foster critical thinking, decision making, delegation, and team work. Simulation experiences are made possible through the use of technologically-equipped mannequins. This kind of hands-on work offers students various case scenarios and can present students with situations they may not encounter during their assigned clinical rotations.

HPS facilitate the application of theory to practice. According to Tilghman (2006), incorporating new technologies in nursing education provides an opportunity to heighten student learning. These devices also provide future nurses with the skills necessary to flourish in a healthcare market that focuses on the development of technologies to promote patient safety and improve their outcomes.

HPS represent the most up-to-date simulation technology utilized by educators to instruct healthcare providers at all levels and in all disciplines (Bremner, Aduddell, Bennett, & VanGeest, 2006). Simulation also provides an objective way to assess and evaluate students' decision-making processes prior to actual live patient contact. The HPS can be used to create clinical situations that help students bridge theory and practice in a controlled environment, permitting students to focus without fear of harming an actual patient (Spunt, Foster, & Adams, 2004).

Review of the literature

In a systematic review of quantitative studies to determine the effect of simulation on education and learning, Ravert (2002) collected 513 references related to computer-based and healthcare simulation. Of these studies, 23 clearly involved simulation and only nine were quantitative. Seventy-five percent of the studies had positive results of simulation in respect to skill development and/or knowledge acquisition (Ravert, 2002). The review author identified the need for more research that focuses on the most effective way to use simulation. The disadvantages noted in previous studies were the inconsistencies in the patient outcomes related to the simulation experiences presented, as well as the cost of high-fidelity HPS.

A study was performed to investigate the effects of using HPS for remediation of graduate-level nurse anesthesia students, compared to the traditional method of addressing students' knowledge deficits before returning them to the clinical setting (Leah & Koop, 2004). The students who were weak in the clinical settings worked in a simulation center with HPS that were preprogrammed with standardized case scenarios. Each student's mannequin was programmed by the instructor to strengthen his or her area(s) of weakness in the clinical arena. The researchers discovered that the most important aspect of remediation was debriefing, which could determine how much more simulation practice the student needed (Leah & Koop, 2004).

Research examined whether the use of HPS would address problems faced in the traditional descriptive-teaching style (McCausland, Curran, & Cataldi, 2004). Using the nursing process as the framework, 72 nursing students in a baccalaureate program participated in the study. The educators created simulation objectives around congestive heart failure (CHF). The clinical presentation and a simulation of a physician's orders were incorporated and tailored to meet the objectives. The students were provided with reading materials and objectives and were instructed to review the drugs used in CHF. The educator's role was to serve as a facilitator. Eighty-three percent of the students indicated that pre-scenario reference materials were helpful. Eighty-two percent indicated they had come prepared to make decisions. Ninety-seven percent of the students indicated that the simulation experience would help them when confronted with actual critical situations in the future. Ninety-six percent believed that the simulation taught them significant lessons and that debriefing was beneficial. The experience was rated as positive by 90%, with 58% indicating the experience was excellent (McCausland et al., 2004).

An exploratory descriptive study was performed to evaluate the advantages and limitations of using high-fidelity HPS to simulate clinical scenarios (Bearson & Wiker, 2005). The researchers substituted a 2-hour session using the HPS for 1 clinical day for 2 groups of first-year baccalaureate students. The number of students was not specified. These students were doing their clinical rotation with postoperative patients. Each student group was given 3 different scenarios in the simulation class, which were related to postoperative patients. Each student group provided total care for 2 consecutive hours using the HPS. The results, using the Likert scale, indicated increased knowledge of medication side effects and differences in patients' responses, and the confidence and ability to administer medications safely.

A pilot study was performed with 21 senior-level medical-surgical nursing students (Rhodes & Curran, 2005). Their goal was to improve the students' critical thinking skills. Rhodes and Curran used HPS to facilitate this process. A 13-item survey developed by the faculty was given to the students and addressed their perceptions of the simulation experience. The results were positive. Faculty noted that students were able to accomplish the simulation objectives addressing physical assessment and skill acquisition related to IV monitoring, urinary catherization, and blood transfusion. They noted that the students' main area of weakness was the procedure for blood administration. The results indicated that the HPS was an effective tool to promote critical thinking related to patient care (Rhodes & Curran, 2005).

In 2004, 190 students participated in a study that was developed by the University of Maryland Baltimore School of Nursing, based on Benner's theoretical framework addressing the attributes and learning needs of nurses at varying degrees of clinical competency (Larew, Lessans, Spunt, Foster, & Convington, 2006). Benner's theory states that students with higher competency levels should be able to develop a nursing diagnosis and intervene faster based on the subtle cues of the simulated patient (Larew et al., 2006). The objective of the project was to address the needs of the novice practitioner. Students worked with standardized, clinically accurate data that was programmed into SimMan. The study demonstrated that novice students needed more prompts before diagnosing the problem than those students with higher levels of competencies (Larew et al., 2006). The study also supported Benner's theory that students with higher competency levels would be able to develop a nursing diagnosis and intervene faster than the less competent students (Larew et al., 2006).

A pilot study evaluated the learning outcomes of students using the Laerdal SimMan HPS (Radhakrishnan, Roche, & Cunningham, 2007). A convenience sample (10 females and 2 males) of homogeneous second-degree, senior baccalaureate nursing students were studied to compare their clinical performance with and without HPS exercises and to identify areas in which the use of HPS was beneficial. Students in groups of 6 were randomly assigned to the intervention or control group. Those involved in the study had previously completed 320 hours of internships. Performance addressed safety, basic assessment, prioritization, problem-focused assessment, appropriate interventions, delegation, and communication. Students in both groups were evaluated at the end of the mandatory simulation exercise by using the Clinical Simulation Evaluation Tool (CSET). The results indicated that in safety and basic assessment, students in the intervention group scored higher. In focused assessment, interventions, delegation, and communication, no significant difference was noted between the intervention and the control groups (Radhakrishnan et al., 2007).

Effectiveness in clinical simulations

Studies related to the use and effectiveness of HPS show they may be utilized to test each student's level of clinical competency and critical thinking skills (Rhodes & Curran, 2005). HPS are effective at all levels of education (graduate and undergraduate), but they are also time-consuming and costly to utilize (Hravnak, Tuite, & Baldisseri, 2005; Leach & Koop, 2004; McCausland, 2004).

The use of HPS facilitates the development of students' physical assessment and critical thinking skills, which are essential for providing effective and efficient care. Simulation technology cultivates the refinement of nursing competency without the student being in an actual clinical environment (Larew et al., 2006). Case scenarios should also be created by faculty experts in the field. Faculty must be familiar with and comfortable in using HPS and scenarios should coincide with current lecture content.

Future uses

The future use of HPS will provide more opportunities to expose students to acute patient scenarios in which they can intervene safely. Exposing students to HPS on a regular basis throughout the curriculum would enable faculty to present case scenarios in which the students would be developing basic skills. The complexity of the cases can be increased over time to integrate technical skills and promote critical thinking. Also, review of videotaped student-HPS interactions and the debriefing process would provide for both quantitative and qualitative research and is supported by Larew and colleagues (2006). Utilization of simulation technology would also enable the faculty to provide 1:1 supervision of clinical competencies for each student and would facilitate tailoring remediation to meet individual needs.


The HPS can be an effective tool for students and faculty to use in combination with other teaching methods to facilitate mastery of clinical skills and promote critical thinking. Studies are needed, however, with larger sample sizes to expand and validate previous findings, particularly with undergraduate nursing students. Expanded research would add to the reliability of studies to date and facilitate the development of programs to meet students' needs. Qualitative studies looking at HPS use demonstrate positive results. However, more quantitative studies are needed to demonstrate effectiveness. Standardized objective measurements should be formulated to measure student outcomes.

In addition, debriefing is essential to the simulation process because it allows the student to view his or her performance and discuss it with the instructor (Larew et al., 2006; Henneman & Cunningham, 2005). By utilizing debriefing, the students' strengths and weaknesses can be evaluated and appropriate changes can be made to address the students' needs.

The author anticipates that HPS and simulation technology will be used more often as patient acuity rises and competition for clinical placements increases. Nursing faculty will play a vital role in this process through the development of theory-based simulation protocols that focus on the essential elements of nursing practice. The patient-simulation medium provides opportunities for student learning that utilize critical thinking and hands-on experience for skill development and assessment (Larew et al., 2006). HPS and simulation technology will continue to play an important role in developing nursing students' clinical competencies in controlled environments.


Bremner, M., Aduddell, K., Bennet, D., & VanGeest, J. (2006). The use of human patient simulators: Best practices with novice nursing students. Nurse Educator, 31(4), 170-174.

Gaba, D. M., & DeAndra, A. (1988). A comprehensive anesthesia simulation environment: Recreating the operating room for research and training. Anesthesiology, 69(3), 387-394.

Herrmann, E. K. (1981). Mrs. Chase: A noble and enduring figure. American Journal of Nursing, 81(10), 16.

Larew, C., Lessans, S., Spunt, D., Foster, D., & Covington, B. (2006). Innovations in clinical simulation: Application of Benner's theory in an interactive patient care simulation. Nursing Education Perspectives, 27(1), 16-21.

McCausland, L., Curran, C., & Cataldi, P. (2004). Use of a human simulator for undergraduate nurse education. International Journal of Nursing Education Scholarship, 1(1), 1-17.

Nehring, W., Lashley, F., & Ellis, W. (2002). Critical incident nursing management using human patient simulators. Nursing Education Perspectives, 23(3), 128-132.

Peteani, L. (2004). Enhancing clinical practice and education with high-fidelity human patient simulators. Nurse Educator, 29(1), 25-30.

Radhakrishnan, K., Roche, J., & Cunningham, H. (2007). Measuring clinical practice parameters with human patient simulation: A pilot study. International Journal of Nursing Education Scholarship, 4(1), 1-11.

Ravert, P. (2002). An integrative review of computerbased simulation in the education process. Computers, Informatics, Nursing, 20(5), 203-208.

Rhodes, M., & Curran, C. (2005). Use of the human patient simulator to teach clinical judgment skills in a baccalaureate nursing program. Computers, Informatics, Nursing, 23(5), 256-262.

Saba, V. K., & McCormick, K. A. (2006). Essentials of nursing informatics (4th ed.). New York: McGraw Hill.

Spunt, D., Dawn, M., & Adams, K. (2004). Mock code: A clinical simulation module. Nurse Educator, 29(50), 192-194.

Tilghman, J. (2006). Innovation approaches to use of technological advances in nursing education. American Black Nurses Faculty Journal, 17(3), 99.

Alsacia L. Pacsi, MS, RN, FNP, CEN, CCRN

Alsacia L. Pacsi is a nursing lecturer at Lehman College, City University of New York in Bronx, NY. She specializes in emergency and critical care nursing and is a doctoral nursing science student at the City University of New York Graduate Center. This paper was inspired by a course assignment by Margaret Lunney, PhD, RN.
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Author:Pacsi, Alsacia L.
Publication:Journal of the New York State Nurses Association
Article Type:Report
Geographic Code:1USA
Date:Sep 22, 2008
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