Simulation Answers Nursing Need

Editor’s Note: This is part two of a three-part series on initiatives across the country to relieve an expected future nursing shortage by supporting nursing students today.

Although it may be hard to believe, given the present economy all indicators point to drastic nursing shortages in the U.S. in the next 2 decades. A shortage all nurse educators can agree upon, besides the shortage of nurse faculty, is the scarcity of clinical environments available to nursing programs; one of the major reasons nursing schools must tightly limit the number of students they can accept at any given time.

One solution to a clinical site shortage is simulation, a vital tool being integrated into many nursing programs across the country. The expectation is laboratory simulation will not only lessen the problem, but also produce nurses who are better able to react quickly and solve problems in real-life clinical situations.

Combined with clinical experiences and the use of standardized patients (actors), simulation can help educate more nurses and greatly enhance each student’s education, thus producing more highly-skilled nurses. It also makes it easier for nurse educators to objectively evaluate a student’s ability to perform well in a real crisis.

New Paradigm

However, despite the advantages: “The research in simulation is still embryonic,” according to Pamela Jeffries, PhD, RN, FAAN, ANEF. “We’re learning students are more self-confident when caring for simulated patients prior to caring for real patients. In addition, students are very satisfied with this type of teaching methodology; they want more.”

Jeffries, a nationally recognized expert on nursing simulation and associate dean of academic affairs at Johns Hopkins University School of Nursing, Baltimore, says she sees clinical simulations as “a new clinical redesign for clinical education in nursing.” That’s because traditional clinical education is not working as well as it once did.

“We have been teaching students using the same traditional clinical models for decades,” she said. “There is evidence we do not prepare the graduates needed by our clinical partners today. Going to real clinical time, the experiences are random, unpredictable, and often times, not always what students need. In real clinical time, instructors or primary nurses step in to facilitate students because there is a human being who needs immediate attention and care. Students do not get to provide nursing interventions at times on the unit when quick assessments and decisions need to be made.”

Simulation allows students to actively engage an entire set of skills that few will ever have the opportunity to use during traditional clinical placements in real-life settings. And with hospitals increasingly regulating what students can and cannot do, nursing students have fewer chances to hone skills on actual patients.

Actively Engaged

Simulation has another advantage – teaching teamwork. At the University of Texas Arlington’s College of Nursing, nursing and medical students learn how to work together and how to react to a variety of patient scenarios in an entirely simulated facility called the “Smart Hospital.”

This 23-bed, 13,000-square foot simulation facility, opened in 2007, features more than 30 computerized mannequins and 40 standardized patients (actors/actresses). It is a national demonstration center for education of healthcare providers and research and development of healthcare innovations.

The Smart Hospital was established to address two concerns, explained Elizabeth Poster, PhD, RN, FAAN, dean of the University of Texas Arlington College of Nursing. First: not enough clinical settings available. Second: educators had very little control over student experiences in clinical settings.

“If you want a student to be involved in caring for a patient having cardiac arrest, it is not likely they will have an opportunity more than once, if ever, as a student,” Poster said. “Yet in simulation, a student can have this experience many times and become proficient and confident in their interventions.

“High-risk events are very amenable to simulation,” Poster said. “Students absolutely feel they can learn in a more controlled environment because they know a real patient is not at risk.” However, the expectations for care are still the same.

Just because students feel more comfortable with mannequins doesn’t mean they don’t become emotionally involved just as with live patients, emphasized Poster. “I can assure you students feel it is a real experience. A remarkable sense of reality is created. If a mannequin baby dies, students can be upset and experience feelings similar to when a real patient dies under their care.”

Besides learning to react and think during patient crises, Poster said students can also learn good habits in simulation. Good handwashing behavior is a prime example. Students are expected to wash their hands as they would in a real hospital and eventually “it becomes a habit that will continue after graduation.”

UTA’s CON uses up to 50 percent of their clinical time in clinical courses using simulation; and this is allowed by the Texas Board of Nursing.

“The curriculum drives what happens in simulation,” Poster explained. “We believe simulation is a very useful methodology, and we use objective evaluation measures that show our students meet course objectives.” One more plus ? faculty can objectively evaluate students because all students are able to react to the same scenarios, which are video and audiotaped.

Informatics Integrated Into Simulation

The University of Kansas School of Nursing (KU), Kansas City, KS, is another institution taking full advantage of simulation.

The school has partnered with Kansas City, MO-based Cerner Corp. to take the lead in integrating the use of a live-production, clinical information system into students’ simulation experiences.

The partnership resulted from Institute of Medicine (IOM) reports in 1999 and 2001, which validated the integration of IT into the preparation and core clinical competencies of all health professionals.

Helen R. Connors, PhD, RN, FAAN, is executive director of the KU Center for Health Informatics, which houses the program known as SEEDS (Simulated E-hEalth Delivery System), launched in 2001.

SEEDS took a live clinical information system and redesigned it so it follows the educational workflow, embedding it into the curriculum. Nursing students at KU go into an electronic health record to view a virtual patient’s health history and orders just as they would in a real hospital. They find out where the patient is located in the healthcare system, view medications and other orders that have been prescribed for the patient and obtain patient education materials within the simulated electronic health record.

“It’s all at their fingertips: the diagnosis, symptoms, medications and treatment,” Connors said. “We’ve tied it all together with simulation.”

Medical students write orders, she explained, and nursing students carry them out. This teaches them both the dynamics of working together.

According to materials promoting the SEEDS program, “there is an expectation that new graduates will enter the workforce having made the transition from the manual to the automated practice of healthcare; yet, until now, there has been little opportunity for teaching these necessary skills in the curricula.”

KU works with other schools interested in using the system. About 40 campuses are currently using it, with KU working with some of them. “We manage the system for our clients and are the only ones that can mess with the back end,” explained Connors. “But working with other schools has really helped to advance the functionality of the system. They have great ideas.”

Balancing High Tech & Traditional

The University of Texas Arlington School of Nursing uses simulation for about half of their students’ clinicals, while KU uses less. But what is the ideal balance of simulation versus traditional clinical experiences?

Currently, there is very little research on the teaching method to give clear-cut answers, beyond what students and nursing educators have experienced.

However, the National Council of State Boards of Nursing (NCSBN) has recently begun a large, landmark study regarding this. Their research involves 10 schools ? five baccalaureate and five associate degree programs to examine the effects of simulation experiences when integrated throughout the pre-licensure nursing curriculum and substituting for clinical hours.


Students participating in the study are randomized into three groups. The first control group will learn in a traditional manner with 10 percent or less of simulations; the second group will have clinical time replaced with 25 percent of simulations; and the third group will have simulations and clinicals divided equally across six core courses. Students will be evaluated on clinical competency and nursing knowledge and followed into their first year of practice.

Jeffries said until the study is complete, she doesn’t know the ideal balance; however, she is “very satisfied with immersing students into clinical simulation as long as it is well developed, appropriate, reflects real clinical practice, and faculty are trained to implement this type of pedagogy.”

Ironically, one of the barriers to simulation is the resistance of many nurse educators to learn the technology themselves in order to use it as a teaching method. Others simply are too busy to prepare simulations because of their heavy workloads.

“I believe we can replicate all we can do in real clinical,” Jeffries offered. “Many will say we need the human response piece, but by using standardized patients, we can obtain that component too.”

Lisa O. Monroe is a frequent contributor to ADVANCE.

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