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The birth experience: learning through clinical simulation.

The use of clinical simulation prepares practitioners for real world hands-on practice. In the past ten years clinical simulation has been incorporated into nursing programs across the country. It is important to have the fiscal resources along with expert personnel to successfully use clinical simulation to augment the learning experiences for practitioners (Jeffries, 2012). The purpose of this article is to share teaching-learning strategies through use of low-fidelity, medium-fidelity, and high-fidelity simulation with an emphasis on high-fidelity simulation through the use of birthing simulation mannequins. The use of clinical simulation to teach practitioners about the birth process will be emphasized. Throughout the paper, we will mesh how nurse educators and practicing nurses can collaborate together and provide prenatal classes on a college campus to teach new parents and students. Additionally, hospital nurse educators have used simulation as a way of evaluating competence of nurses with skills used on maternal/child units.

Preparing for Clinical Simulation

Fiscal Planning

Nurse educators must have fiscal plans for the use of clinical simulation in their educational programs. Nursing administrators must budget for the use of low through high-fidelity simulation as the costs of this equipment can tax fiscal resources. The cost of a high-fidelity adult size birthing mannequin can range from $56,000 to $60,000.

The cost of upgrades must also be considered. Cameras and other audio-visual equipment costs have to be factored in when purchasing high-fidelity equipment. Purchasing recording and debriefing solutions, wireless and hard-wired cameras for multiple video and audio streams cost approximately $13,000. Many vendors will offer on-site training that will add another $2,500-$3,000. Be sure to plan for warranty costs because equipment parts often need to be replaced. The four-year warranty for one high-fidelity birthing mannequin can cost close to $3,000. It is important to consider the cost of replacement parts when determining if the costs of purchasing warranties will be a wise use of fiscal resources. For example, the motherboard motor (birthing propulsion piece) is a part that is frequently replaced. and the replacement cost is $7,500. Clearly purchasing the warranty is a wise course of action.

Human Resources--Simulation Specialist

Nurse administrators must plan to hire experts in clinical simulation. In reviewing the literature a common theme was that expensive equipment remained in boxes because staff nurses did not have the specialized training needed to set up and use the equipment. For example, the program at Morehead State University hired a person that was technology-savvy with a clinical background in critical care, operating room, and emergency department (ED). This person also was a traveling injection training nurse. Initially this support staff person was hired as their laboratory coordinator. As programmatic needs changed to include teaching technologies and the interests of the laboratory coordinator became more focused in clinical simulation this person was supported to attend focused workshops on use of medium through high-fidelity simulation equipment. The position evolved into a Simulation Specialist role. The reader is referred to Box 1 to review and example of the Simulation Specialist's role in an academic setting.

The Simulation Specialist works in collaboration with the Patient Care Lab Coordinator and nursing faculty to provide high quality, realistic clinical experiences to nursing students in four different clinical labs that comprise the Simulation Through Advanced Technology (STAT) Nursing Center. Work in the STAT Nursing Center focuses on immersing students in scenarios using the latest in patient simulators, facilitating an environment as true to life as possible. In the STAT Nursing Center, students are provided opportunities to make the types of decisions and perform functions required of nurses upon graduation and knowledge needed to be successful on the registered nurse (RN) licensure exam. In hospital practice, the simulation specialist can use equipment to determine competency of staff using low-fidelity and high-fidelity simulators such as cervical dilatation and effacement models, abdominal palpation models, gestational wheels, postpartum fundus models, and birthing and newborn mannequins.

Clinical Simulation

Clinical simulation strives to reproduce aspects of any given clinical practice situation to prepare the practitioner for hands-on clinical practice. Nurse educators teach psychomotor practice skills in laboratories, foster critical thinking and analysis, emphasize patient safety and build confidence for decision-making through varied clinical simulation scenarios. Nursing research supports that clinical simulation enhances student nurses' ability to think critically (Goodstone et al., 2013). Within the last 10 years technology has offered more sophisticated learning experiences for nurses. Simulation appeals to tech savvy students who want to be more engaged in active learning who view classroom lecture as a more mundane learning mode (Starkweather & Kardong-Edgren, 2008). Learning through the use of clinical simulation includes use of electronic health records, automated medication dispensing systems, and the use of clinical simulation to prepare the student in a safe laboratory setting prior to practicing the skill on a human being. Clinical simulation can be easily adapted to community childbirth education classes to facilitate understanding of the labor and delivery process.

Low-Fidelity Simulation

Historically, nurse educators have used case studies to teach both didactic and clinical content. Working in small groups or individually, nursing students drew upon knowledge from previous courses and newly learned information to address physical assessment needs, plan nursing care, and select appropriate interventions to provide care to patients through answering focused questions posed by the nurse educator. This form of low-fidelity simulation is widely used in nursing programs and hospital staff development sessions today.

In the STAT Nursing Center at Morehead State University other forms of low-fidelity simulation include role play where the student nurse assumes other roles to learn about other position responsibilities such as phlebotomist, unit secretary, and the charge RN role. Computerized games are developed to help students learn about medications and their side effects as well as computerized assisted instruction (CAI) that can be used to teach any specialty in nursing.

Low-fidelity learning strategies can be performed by students independently in a non-threatening lab environment. Another excellent example of low-fidelity simulation is cardio-pulmonary resuscitation (CPR) practice on mannequins. These and other experiences need to be available to students during open lab times when both the Patient Care Lab Coordinator and Simulation Specialist along with clinical faculty can be available to nursing students using STAT Nursing Center resources. Every student nurse can learn by practicing and participation in low-fidelity simulation activities. Research supports that confidence increases after learning information in low-fidelity practice, such as CPR (Healy et al., 2010). Based upon simulation experiences, information in nursing programs can be revised to reflect accurate learning needs of nursing students. In practice settings, this translates to having the same simulation equipment available in nursing departments.

Students are scheduled for a campus lab day early in the semester where obstetric skills are demonstrated by the instructor. The STAT Nursing Center is equipped with low-fidelity OB equipment such as: cervical dilatation and effacement models, newborn models of various ethnic backgrounds, an empathy belly and an abdominal palpation model, a postpartum fundus model with an interchangeable firm and boggy fundus, gestation wheels, and injection teaching models. These low-fidelity simulation models are used for faculty demonstration and student practice.

Case studies are excellent tools for hospital staff development coordinators to teach new nurses the skills required to practice in the maternal/child setting. In nursing school these same case studies are incorporated into the course to enhance students' clinical decision making during the provision of obstetric nursing care. Clinical instructors use case studies in the campus laboratory and/or the clinical post-conference setting. Case studies are utilized to enhance student learning in labor and delivery, post-partum and newborn care. Low-fidelity equipment in the laboratory is used to demonstrate skills and physical assessment related to the specific case study assigned.

Students are randomly placed in small groups of three to four. They are provided with learning objectives and scenarios related to specific OB content. Students collaborate with group members and utilize clinical decision making skills to complete the case study. Then each group presents assessment data, nursing interventions and a plan of care specific to the low-fidelity simulation. Refer to Box 2 for an example of a low-fidelity OB case study.

Medium-Fidelity Simulation

Medium-fidelity simulators are used to teach specific procedures through use of lower-tech mannequins, computerized IV therapy insertion arms (Figure 1), nasogastric feeding pumps and other invasive procedures such as urinary catheter insertion. Cost of this equipment varies; however, IV arms start at $660. Most of these procedures can cause discomfort to patients and potential awkwardness for the student nurse performing a procedure for the first time. The STAT Nursing Center is a safe learning environment for the student and allows the student to make a mistake without harm to a patient.

When cost is a consideration, medium-fidelity simulators offer a less expensive alternative to buying more of the higher expense high-fidelity mannequin that often requires more than one person to operate (Cunningham, 2010). In nursing schools and hospital education settings participants are checked off on specific skills which are easily done through use of medium-fidelity simulation equipment.

High-Fidelity Simulation

In the obstetrics setting, especially labor and delivery, nurses new to the setting and student nurses often feel unprepared to take an active hands-on role because their experience has been primarily observational. Nursing professors have reported that students are anxious in the practice laboratory setting for this same reason (personal communication, Vanessa Sammons, February 6, 2014). Repeated practice in lab settings in nursing programs will go far in allaying the student nurses' fear when they enter hospital practice settings.

Repeated clinical practice through use of high-fidelity simulation offers the learner a realistic opportunity to interact with a computerized mannequin while being filmed and recorded (Parsons, 2013). The audio features of high-fidelity mannequin's mimic sounds such as vomiting, crying, yelling and a myriad of other life-like sounds heard in nurse practice. The mannequin can be programmed to have an arrhythmia, seizure or other untoward event that tests the student nurses ability to appropriately intervene for the patient.

Nurse practice in the clinical laboratory setting for obstetrics can create anxiety. Nursing assessment skills, selecting the most appropriate nursing interventions, verbal and nonverbal communication techniques and patient and family teaching are basic nursing competencies that students can refine and improve upon. Debriefing sessions offer the learner constructive feedback from peers and nurse educators. Nurse educators use information obtained from simulation experiences that facilitate change in nursing curriculum across the entire program of study.

Theory and clinical components of OB are taught simultaneously. High-fidelity simulation is incorporated at the end of the course to validate the learner's competency or identify areas of weakness in obstetrical care. Clinical experiences that were not available due to low patient census or lack of clinical sites can be obtained through the simulated experience. Through the use of evidence-based scenarios during high-fidelity simulation, learners can participate in a realistic labor and delivery experience. The birthing room is fully equipped with a functioning delivery bed, electronic fetal monitor, birthing cart, headwall unit, radiant warmer, oxygen and suction devices (Figure 2). Simulation for OB uses high-fidelity birthing and newborn simulators which fosters a realistic experience. For example, the STAT Nursing Center has a control room behind one way glass where faculty can observe students during the simulated experience (Figure 3). Overhead cameras record the simulation from different angles during simulation. Students are oriented to the STAT Nursing Center prior to the simulation experience. This facilitates a relaxed learning environment. Learning objectives and basic information about the scenario are provided a few days prior to the simulation so that the environment doesn't overwhelm the students during the simulation and they can focus on the care of the patients. In the hospital setting, a labor and delivery room can be used to set up a simulation of the birthing process to foster competency of nursing skills used in the care of mothers and babies.

Students utilize the STAT Nursing Center Blackboard site and complete a tutorial Simulation Orientation Tricks and Tips prior to the simulation. Students are typically in groups of 3-4 when they receive report on their patient. Students must delegate patient care (i.e. patient assessment, intravenous access, medication administration, vaginal exam, set up delivery cart, notify obstetrician) (Figure 4). Medication carts and an automated medication dispenser system are also available for student use.

The Simulation Specialist can perform multiple duties (secretary, pharmacist and supplies) during the simulation. Colored vests are utilized to distinguish between the various roles (assistants, family, pharmacy, etc.). Interprofessional communication is incorporated into the simulation. Students are given provider contact information to facilitate interprofessional collaboration. A unit secretary is at the nurses' station to assist with contacting providers. These teachinglearning strategies are implemented across the nursing curriculum in all clinical-related courses.

Scenario progression is based on learner actions. A normal delivery can turn into a precipitous birth if the student does not utilize critical thinking and clinical decision making skills (Figure 5). For example, if the learner fails to provide the appropriate standard of care after the patient delivers, the patient can hemorrhage thereby simulating a high-risk patient environment. The newborn sequence of events can vary depending on student actions (normal newborn, respiratory distress, cyanosis [Figure 6], seizure activity, hypoglycemia or death). An electronic medical records system with mobile carts is available for participants to utilize real world technology. Participants are required to document care in the electronic system.

Debriefing is held immediately post simulation where students discuss and reflect on their performance. The debriefing process is guided by faculty to facilitate student interaction. During debriefing. students will bring in knowledge of previous course work in mental health, anatomy and physiology, pharmacology, physical assessment and basic nursing practice skills. They can view the simulated experience via recorded video to discuss strengths, weaknesses, and identify interventions that could potentially improve patient outcomes.


Traditional lecture format does not completely meet the unique needs of learners. Clinical simulation facilitates auditory, visual and tactile learning. Thanks to advanced technological advances the use of low, medium and high fidelity simulation has augmented teaching fundamental and advanced nursing practice skills. Nurse educators must plan for use of clinical simulation from both a fiscal and human resource standpoint. We can ill afford to pay thousands of dollars for equipment to sit in a box due to lack of knowledge for set-up. the use of advanced technologies augments traditional programs in teaching maternal/child nursing and obstetrical skills. Employing simulation specialists in both hospital and academic environments is highly desirable, having nurses with skills in teaching technologies and whose programs of scholarship focus on data based interventions will advance preparing nursing students for the 21st century.


The authors would like to acknowledge Ruth Huffman, Simulation Specialist at Morehead State University for her assistance in providing information for this manuscript. Her expertise in teaching nursing students and assisting nurse faculty with clinical simulation has helped to prepare hundreds of our graduates for clinical practice.

Box 1. Simulation Specialist Job Description in
Academia--Simulation Specialist (Nursing)

Job Summary

The Simulation Specialist (Nursing) provides technical and general
support in the development and use of simulation learning for all
nursing programs at Morehead State University. Prepares and
maintains simulation center equipment and supplies, media,
computers, proprietary/licenses, and materials related to learning
in a virtual hospital or virtual specialty unit settings to ensure
that faculty and students are able to perform skills safely and
accurately and that equipment and supplies are available for
subsequent simulation experiences. Maintains compliance and
standards as applicable. Participates as part of faculty teams that
plan curriculum for the simulation center, develops scenarios and
assists faculty with the preparation and implementation of the
virtual hospital and/or specialty unit scenarios. Provides
instruction and orientation to the simulation center users. Teaches
assigned classes to address specific learning outcomes in
accordance with approved course descriptions and expected student
learner outcomes as designed by faculty. Serves as liaison with
community groups in the instruction of interprofessional groups
and/or use of the simulation center in accordance with departmental
policy. Maintains accurate and current website for the simulation
center and for the department of nursing.

Duties and Responsibilities


* Provides technical and general support in the
development and use of simulation learning for all
nursing programs at Morehead State University.

* Prepares and maintains simulation center equipment
and supplies, media, computers, proprietary/licenses,
and materials related to learning in a virtual hospital
or virtual specialty unit settings to ensure that faculty
and students are able to perform skills safely and

* Ensures equipment and supplies are available for
simulation experiences.

* Maintains compliance and standards as applicable for
current simulation learning experiences including use
of current simulation technology.

* Recommends simulation purchases to committee with
faculty input.

* Collaborates with IT Specialist and Multimedia
Laboratory Coordinator and MSU Information
Technology to maintain stable technology

* Assists Academic Resources/Lab Coordinator at
satellite campus and Patient Care Laboratory
Coordinator as needed.

* Keeps abreast of current literature and issues relevant
to simulation.

* Supervises work study students as assigned.

* Teaches selected Department of Nursing courses as

* Participates in department, college, and University
meetings and committees as appointed.

* Represents department, college, and University at
professional and/or community activities.

* Participates in department recruitment activities.

* Provides professional community services as
opportunities arise.

* Performs other job related duties as assigned by

Simulation Support

* Maintains currency in use of clinical simulators and
programs that support simulation.

* Collaborates with Information Technology to facilitate
simulation scenarios

* Collaborates with faculty and patient care laboratory
coordinators for best practices in simulation.

* Teaches assigned classes to address specific learning
outcomes in accordance with approved course
descriptions and expected student learner outcomes as
designed by faculty.

* Provides instruction and orientation to the simulation
center users and in the use and care of simulation
equipment and in safety procedures.

Budget and Financial Oversight

* Responsible for inventory to support simulation and
ordering supplies in collaboration with Patient Care
Laboratory Coordinator.

* Uses financial tracking system to provide cost analysis
for simulation experiences designed by faculty teams.
Reports cost analysis to respective Course Leaders and
Program Coordinator.

* Investigates current software to support simulation
including EMR, other related software and provides
financial projections to Program Coordinators/Chair.

Community Liaison with Simulation

* Serves as liaison with community groups in the
instruction of interprofessional groups and/or use of
the simulation center in accordance with departmental
policy. For example, the simulation specialist could
partner with a community childbirth educator to use
simulation in prenatal classes for parents on campus.
Nursing students could participate in a service
learning opportunity which would benefit both the
students and childbearing families in the community.
Childbirth educators could utilize low fidelity scenarios
with assistance from the simulation specialist where
childbearing families could be taught concepts such
as dilation and effacement. High fidelity mannequins
could be used for a simulated birth experience during
childbirth classes.

Web Page and Media

* Assists with ongoing development and maintenance of
the Department of Nursing Web site.

Nursing Expertise

* Documents continuing education related to current
technical and educational practices in nursing.

* Maintains clinical expertise and licensure as a
registered nurse.

Organizational Relationships

The Department of Nursing Simulation Specialist reports
to the Department Chair of Nursing. Incumbent supervises
nursing and work-study students as assigned. This
position interacts with faculty, staff, and students.

Minimum Requirements

Master's Degree in nursing is required. Eligible for current
licensure to practice as a registered nurse in the Commonwealth
of Kentucky. Experience in clinical setting
utilizing general nursing skills with a minimum of two (2)
years' experience. Membership in national organization
that educates and promotes knowledge in simulation in
nursing Demonstrated experience in the use of computer
hardware and software. Minimally, experience in the use
of low fidelity simulators. Effective communication and
interpersonal relationship skills.

Additional Desirable Qualifications

Web site design, editing, and maintenance.

Low-Fidelity OB Case Study

Lucia Ramirez, a 16-year-old Latino G1P0. is 34 weeks
pregnant attending childbirth education classes with
her 21 year-old-boyfriend. She states that she really
wants to breastfeed her baby but her Mother thinks
that she should give the baby formula instead. She
asks for information about breastfeeding.

Learning Objectives

The mother will:

1. Discuss the benefits of breastfeeding her baby.

2. Identify cues indicating that the baby is ready to

3. Demonstrate correct latch and positioning for
breastfeeding her baby.

What benefits of breastfeeding should the childbirth
educator explain to Lucia and her family?

1. What cues indicate that Lucia's baby is ready to

2. What are the different positions that can be used
for breastfeeding?

3. How often should the childbirth educator tell Lucia
breastfeed her baby?

4. How would the childbirth educator explain to
Lucia to determine if the baby is breastfeeding effectively?


Cunningham, D. D. (2010). Incorporating medium fidelity simulation in a practical nurse education program. Journal of Practical Nursing, 60(1), 382-288.

Goodstone, L. Goodstone, M. S., Cino, K., Glaser, C. A., Kupperman, K. & Dember-Neal, C. A. (2013). Effect of simulation on the development of critical thinking in associate degree nursing students. Nursing Education Research, 34(1), 159-162.

Healy, A., Sherbino, J., Fan, J. Mensour, M., Upadhye, S. & Wasi, P. (2010). A low-fidelity simulation curriculum addresses needs identified by faculty and improves the comfort level of senior internal medicine resident physicians with in hospital resuscitation. Critical Care Medicine, 38(9), 1899-1903.

Jeffries, P. R. (2012). Simulation in nursing education, 2nd edition. National League for Nursing: New York, NY.

Parsons, L. C. (2013). Leadership and management for every nurse, 2nd edition. Western School: West Bridgewater, MA.

Starkweather, A. R. & Kardong-Edgren, S. (2008). Diffusion of innovation: Embedding simulation into nursing curricula. International Journal of Nursing Scholarship, 5(1), 1-11.

Teresa D. Ferguson has clinical practice experience in women's care/newborn nursery, medical-surgical nursing, and quality management. She was previously certified as a lactation consultant and taught breastfeeding classes in the community setting. She is an Associate Professor of Nursing at Morehead State University and is certified as a nurse educator through the National League for Nursing (NLN).

Teresa L. Howell has 30 years of experience that includes being a Nurse Manager for Medical-Surgical and Maternal/Newborn Acute Care Units. She is a bereavement counselor for ELNEC (End of Life Nursing Education Consortium) where she has earned state and national recognition for her work with children and bereavement. Currently she is an Associate Professor of Maternal/Newborn Nursing and holds NLN certification as a Certified Nurse Educator (CNE).

Lynn C. Parsons has held administrative positions in acute hospital and academic settings for the past 30 years. She has two advanced degrees in administration and is certified as a nurse executive advanced through the American Nurses Credentialing Center (ANCC).

by Teresa D. Ferguson, DNP RN CNE, Teresa L. Howell, DNP RN CNE, and Lynn C. Parsons, PhD RN NEA-BC
COPYRIGHT 2014 International Childbirth Education Association
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2014 Gale, Cengage Learning. All rights reserved.

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Author:Ferguson, Teresa D.; Howell, Teresa L.; Parsons, Lynn C.
Publication:International Journal of Childbirth Education
Article Type:Report
Geographic Code:1USA
Date:Jul 1, 2014
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