URC

Glimpse into Simulation and Critical Thinking:
A Pilot Study Comparing Utah and Ecuador

Katrina Duncan
Patricia K. Ravert*


Abstract

Interviews in Utah and Ecuador explored the perceptions of simulation and critical thinking. Three themes emerged during analysis. High fidelity simulation can be used to develop critical thinking and is used in many Utah nursing education programs, whereas in Ecuador simulation use is in the early stages.

Introduction     

The world of health care is becoming increasingly complex as new treatments, medications, technology, and a greater understanding of conditions evolve by the moment. In both developing and industrialized countries, the nurse fits into this world with a more challenging role than in the past, one requiring a higher level of critical thinking and clinical judgment. New nursing graduates entering the field must, therefore, be better prepared to assume these responsibilities (Lasater, 2007a). The worsening worldwide nursing shortage coupled with the migration trend of nurses, especially in Latin America, coincides with the advancing role of the nurse, augmenting pressure on both nurses and nurse educators. Thus, the use of simulation, specifically to encourage critical thinking, has become a significant aspect in current nursing education in the United States and is in the early stages of development in Latin America.

Confucius said, “I hear and I forget. I see and I remember. I do and I understand.” He recognized that hands-on experience is usually the most effective learning method. Simulation is founded on this idea of doing and practicing. In a variety of disciplines all over the world, simulation has been used for years as pedagogy along with lectures and texts, and the field of nursing is no exception. In nursing, the acquisition of knowledge is not enough; it is the application of knowledge that determines ability and success. Research shows that simulation allows students to retain more knowledge for a longer period of time because they engage in an interactive role that fosters skill acquisition, critical thinking, and confidence (Childs & Sepples, 2006). The purpose of this study was to explore and compare perceptions of the use of simulation in nursing education in an industrialized nation and a developing South American country. Specifically, the study addressed two research questions: (a) what is the role of simulation in nursing education in programs in Utah and Ecuador? and (b) what is the perception of nursing students and new graduates regarding simulation use to improve critical thinking and clinical judgment?

Brief Review of Literature

As the worldwide nursing shortage continues to escalate, adequate preparation of new nurses becomes ever more important. The U.S. Department of Health and Human Services’ Health Resource and Service Administration (HRSA) predicted the nursing shortage in the United States will reach over 1 million by the year 2020. Demand for registered nurses will continue to surge due to the growing aging population and an increasing demand for the highest quality of care. The supply of nurses will dwindle in coming years as the baby-boomer era retires and the number of new nurse entrants remains inadequate (United States Department of Health and Human Services,2004).

In Latin America, the nursing shortage is escalated by the trend of nurses migrating to industrialized nations or other countries within Latin America due to economic instability, low salaries, poor quality of life, and limited opportunities for growth in their home countries (de Leon Siantz & Malvárez, 2008). This decreases availability of both preventative and curative care in these developing nations. Although nursing school enrollment has increased over the last 10 years, it has not been adequate to meet the demand. Many graduating nurses take management positions, leaving the majority of patient care to the nurse auxiliary staff. The percentage of auxiliary staff in Latin America is well above that of the United States. For example, in Ecuador, the auxiliary staff makes up 67.7 percent of the nursing staff, far outweighing the number of professional nurses. The auxiliary staff is trained only in basic skills, further decreasing the quality of care (Malvarez & Castrillon Agudelo, 2005). With an inadequate supply of nurses to satisfy a growing demand worldwide, it becomes crucial that nurses be prepared with strong critical thinking skills and sound clinical judgment to provide the best care possible.

Sound clinical judgment is the outcome of skilled critical thinking. Critical thinking can be defined as “a cognitive process of skillfully analyzing, synthesizing, and evaluating information gathered from or generated from observation, experience, reflection, or communication as a guide to belief or action” (Rhodes & Curran, 2005, p. 257). When critical thinking is applied in a clinical setting, a nurse makes decisions about what to assess, what data mean, what actions to take, and who should perform tasks. The nurse reasons, draws conclusions, and acts appropriately for a specific patient (Rhodes & Curran, 2005). This process is clinical judgment, an essential part of clinical nursing practice and a skill that sets professional nurses apart from those in technical roles. Tanner’s Model of Clinical Judgment breaks clinical judgment into four components: noticing, interpreting, responding, and reflecting.  A rubric developed by Lasater (2007b) defines the components further. Noticing includes focused observation, recognizing deviations from expected patterns, and information seeking. Interpreting includes prioritizing and making sense of data. Responding includes a calm and confident manner, clear communication, well-planned intervention/flexibility, and being skillful. Reflecting concludes the process with evaluation/self-analysis and commitment to improvement. These dimensions provide a standard from which to evaluate critical thinking and clinical judgment (Lasater, 2007b).

Although the literature suggests that simulation can contribute to student development of critical thinking, no studies to date have demonstrated the effect of simulation on clinical judgment (Lasater, 2007b). Simulation in nursing can be defined as “a technique that uses a situation or environment created to allow persons to experience a representation of a real event for the purpose of practice, learning, evaluation, testing, or to gain understanding of systems or human actions” (National League for Nursing, n.d.). Classroom learning is practiced and applied through simulation, thereby increasing critical thinking, clinical judgment, and confidence in the clinical setting.

Many simulation options, varying by complexity and fidelity, are available for use in nursing education. Simulation is classified according to the degree in which it approximates reality. Low fidelity simulation includes experiences that rely on simple technologies such as role-playing, case studies, and static manikins on which specific skills are practiced. A step above low fidelity is moderate fidelity, where the technology includes computer-based self-directed learning systems that present a specific situation. Moderate fidelity also includes more realistic manikins that may have breath sounds, heart sounds, or pulses. The moderate experiences include an opportunity for the learner to not only perform a skill but to also problem solve and make decisions. The most complex simulation is the high fidelity experience, which uses “full scale computerized patient simulators, virtual reality, or standardized patients that are extremely realistic and provide a high level of interactivity and realism for the learner” (National League for Nursing, n.d.). The patient simulator creates a lifelike clinical situation in which students may practice without worrying their decisions might cause adverse effects that would harm a real patient (Jeffries, 2007).

The high fidelity simulator is becoming a standard in nursing schools and hospitals throughout the United States. Latin America has benefited from the theoretical progress with the increasing breadth and depth of nursing knowledge worldwide, but this progress is still not adequately reflected in education, research, or practice. Many nursing education institutions in Latin America are barely surviving the migration trends and nursing shortages, and they are encountering problems raised by budget deficits (Malvarez & Castrillon Agudelo, 2005).  Because of these factors, funds to build simulation centers are limited and resources for training remain slim. However, progress is being made. Over the last 2-3 years, Brazil has begun using high fidelity simulation in nursing education. Last year, the first center for nurse education was opened in Chile at Las Americas University (Eliana Escudero, personal communication, May, 2009). In a search of the literature, no research was found concerning the use of simulation in Ecuador.

Sample and Method

This descriptive qualitative research project by an undergraduate student was undertaken with institutional review board approval. Inclusion criteria for participants included being a current nursing student or a recent nurse graduate in Utah or Ecuador. The nursing student was defined as an undergraduate nursing student currently enrolled in a diploma, associate degree, or baccalaureate degree nurse education program. The recent nurse graduate was defined as a currently employed nurse (registered nurse in the United States, a licensed nurse in Ecuador) who has graduated from a nurse education program in the past 3 years. The 3-year limitation was established in efforts to ensure that the graduate could recall the effect of the role of simulation on his/her abilities as a nurse following graduation.

Participants in Utah were found through purposeful and snowball sampling. In Ecuador, qualifying participants were identified by hospital administrators. In both cases, possible participants were approached in person, through e-mail, or by telephone regarding the study. They were presented with an explanation of the study and an expected time commitment. A total of 12 participants agreed to be interviewed. In Utah, 4 recently graduated registered nurses and 4 current nursing students were interviewed. All Utah participants were white with an average age of 24 years (range 21-30), and all but 1 Utah participant were female. In Guayaquil, Ecuador, 4 licensed nurses were interviewed, all Latino with an average age of 40 years (range 36-45). Two were female, 2 were male, and all had previous experience as auxiliary nurses. As is often the case in international research, communication was an obstacle.  In this study, corresponding with schools of nursing in Ecuador was difficult, made more so by the language barrier. For this reason, accessibility to students while in Ecuador was not possible due to the inability to obtain prior approval from the schools of nursing. Thus, no nursing students from Ecuador were included in this study and the results are limited to practicing licensed nurses.

Once participation was agreed on, an interview time and location was established. The interviews were conducted using an interview guide. The interviews were audio recorded and later transcribed. During interviews in Ecuador, a translator was present, and only the English translation was later transcribed.

Instrument

An interview guide was developed using Lasater’s Clinical Judgment Rubric (2007b) containing open-ended items/questions. This interview guide was translated into Spanish for use with participants in Ecuador. The first item/question on the interview guide explored the use and role of simulation in the course of the participant’s nursing education program. The concluding items/questions explored how simulation specifically affected different areas of critical thinking development and clinical judgment for the participant (see Table 1).

Table 1
Interview Guide                                                                     

  1. Tell me how simulation is/was used in your nursing education program.

    (Note: Read to participant). Critical thinking in nursing is the process of taking information from observation, experience and communication and using it to make a clinical judgment, which guides your care. One model to illustrate this includes 4 aspects of clinical judgment: noticing, interpreting, responding, and reflecting.

  2. Tell me how simulation experiences have aided you in developing your abilities to effectively notice patient status.

  3. Tell me how simulation experiences have aided you in developing your abilities to interpret information.

  4. Tell me how simulation experiences have aided you in developing your abilities to respond to patient condition/status.

  5. Tell me how simulation experiences have aided you in developing your abilities to reflect on experience.

  6. If you could change your program regarding simulation experiences, what would you recommend and why?
Results

The participants were divided into three specific groups during analysis of the interviews. This was done by location and status as a student or nurse in order to compare the data: Utah nursing students (Group 1), Utah registered nurses (Group 2), and Ecuador licensed nurses (Group 3).

During the interviews in Ecuador, despite the presence of an interpreter and a translated interview guide, the language barrier limited information obtained regarding simulation use and practice. During interviews in Utah, with questions regarding learning through the use of simulation, participant answers most often referred to high fidelity simulation even though simulation levels were not specified by the interviewer. This may demonstrate the proliferation of high fidelity simulation in the United States and the trend to associate the term “simulation” with high fidelity simulation.
Through analysis of the qualitative data, descriptive categories and themes were identified. The levels of simulation and different methods, such as case studies and role playing, as well as equipment and items, including manikins, manikin limbs, cadavers, leather, and fruit. were identified (see Table 2). The perceived benefits and drawbacks of simulation use were identified (see Table 3). While analyzing data, themes also emerged among and within groups. The themes included (a) Safety in Practice, (b) Putting it Together, (c) and the Importance of Experience with Reality (see Table 4). The theme Putting it Together was identified in all three groups, whereas Safety in Practice was identified only in the Utah groups. Both groups of licensed (Ecuador) or registered nurses (Utah) identified the Experience in Reality theme.

Table 2
Levels and Methods of Simulation Used

 

Utah Nursing Students

Utah Registered Nurses

Ecuador Licensed Nurses

Low Fidelity

Case Studies

Manikin (static)

Manikin limbs

Role playing

Pin Cushions

 

Case Studies

Manikin (static)

Manikin limbs

Role playing

Fruit

Case Studies

Manikin (static)

Leather/Cloth

Meat

Fruit

Animals

Cadavers

 

Moderate Fidelity

Manikins (with breath sounds, heart sounds)

Computer DVDs

 

Manikins (with breath sounds, heart sound)

 

High Fidelity

Manikin (patients simulator)

Manikin (patient simulator)

 

 

Table 3
Benefits and Drawbacks of Simulation

 

Utah Nursing Students

Utah Registered Nurses

Ecuador Licensed Nurses

Benefits of Simulation

Helpful Practice
Familiar with patterns and changes
Learning in safe environment
Expand theoretical knowledge
Familiar with common situations
Recognize deviation, know response and priorities
Remain calm in stressful situations
Evaluating performance to improve
Treat patient, not just problem
Increase confidence and comfort
Good step in transition from classroom to hospital

Helpful Practice
Familiar with patterns and changes
Learning in safe environment
Expand theoretical knowledge
Familiar with common situations
Recognize deviation, know response and priorities
Remain calm in stessful situations
Evaluating performance to improve
Treat patient, not just problem

Helpful Practice
Familiar with patterns and changes
Learning in safe environment
Expand theoretical knowledge

 

Drawbacks of Simulation

Real patient differs from simulation

Real patient differs from simulation
Little help with patient response and communication

Real patient differs from simulation
Prefer more time learning hands-on with real patient

 

Utah Nursing Students

Utah Registered Nurses

Ecuador Licensed Nurses

Drawbacks of Simulation (continued)

 

Instructor overly involved impeded learning
Hospital experience more valuable

Had learned many skills from prior job

Not learning skills and theory in conjunction

 

Table 4
Themes of Simulation Use

 

Utah Nursing Students

Utah Registered Nurses

Ecuador Licensed Nurses

Themes

 
Safety in Practice

 

 

 

 
Importance of Experience with Reality

 

 
Putting it Together

 

 

Safety in Practice. Throughout interviews with both Utah groups--students and registered nurses--participants often discussed the benefit of using simulation to practice in a safe setting before entering a clinical situation with real patients. Whether simulation allowed a non-harmful setting to practice in case of mistakes, or the experience of simulation created more confidence prior to entering a real patient’s room, Utah students and nurses alike felt practice in a safe setting was invaluable.

One Utah nursing student stated,
I think if you practice in a setting where it is safe to screw up, the more you practice the more comfortable you are with it in real life. So after performing simulation after simulation you get used to the situation and how you should respond.

A registered nurse from Utah explained that she “learned by trial and error in simulation. Sometimes you messed up and the outcome wasn’t quite as good.” The safe setting of simulation offered many Utah nurses and students the opportunity to practice situations and make mistakes, thus preparing them and creating confidence for encounters in a clinical setting with real patients.

Importance of Experience with Reality. Responses from Utah registered nurses as well as licensed nurses in Ecuador demonstrated a theme of the importance of experience with real patients in a clinical setting. Many of the recently graduated registered nurses from Utah expressed the notion that the steepest learning curve of critical thinking and clinical judgment came with on-the-job training during their first job. A registered nurse from Utah said that simulation “wasn’t as helpful at dealing with the idiosyncrasies that occur in actuality and real life.” Instead, it was the experience with real patients in a real setting that most benefited nurses’ thought, decision making, and action processes.

In Ecuador, licensed nurses expressed a similar theme of the greater value of practical experience over simulation. One nurse from Ecuador expressed,

It did help in school to practice, but it’s a lot different than real life…sometimes in simulation you only get to do one thing, but in real life you have to do a lot of different things. So the best practice for me was actually working on real patients in real situations.

Some nurses from Ecuador expressed that it was difficult to learn the proper skills and processes with simulation. Thus, the experience gained during nurses’ time spent in the hospital during school was perceived as most valuable to their critical thinking skills.

Putting it Together. A theme of simulation helping put all the information together existed across all groups, although the Utah nursing students more frequently expressed this. Simulation seemed to be a place for information from books, lectures, labs, and other routes to come together at the level of application. One student from Utah said, “I think from the classroom to the simulator to the patient was a great process to learn . . . . in class, how to apply it on simulators, and then how to really apply it on a patient.” Similarly, recently graduated nurses from Utah shared that simulation offered a chance to actually see and do what had been simply heard about during class and readings.

In Ecuador, the licensed nurses expressed a similar feeling of putting together all aspects of education through simulation. A licensed nurse stated, “First they give us theory, after theory we go to practice. So we see the whole process and what is going to happen. We have theory, practice, and then go to the hospital.”

A nursing student from Utah described how the themes of Safety in Practice and Putting it Together benefited her education.

I think simulation helps because as opposed to just reading it, you are actually doing it. Even though it’s not real life, not a real patient, you are still going through the motions and forming the skills. I think it helps because it is as close to real life as you can be without doing it on a real patient. It increases your ability, increases your confidence, and prepares you better.

Simulation in nursing is seen as beneficial to nurse confidence and as a vital preparatory step in taking classroom thinking to application. However, many recently graduated working nurses noted that the most beneficial critical thinking development and crucial experience comes from stepping outside the simulation lab into a clinical setting.

Summary and Conclusions

Through the interviews and analysis, the data confirm that the technology of simulation in the developing country of Ecuador remains limited, most likely due to lack of available funding and resources. None of the participants interviewed for this study from Ecuador had experience with a high fidelity simulator, although most had used low fidelity manikins in their nursing education. In fact, Ecuador participants did use anything higher than low fidelity simulation. This is in contrast to the participants from Utah, where each participant had at least some experience using high fidelity simulation.

For participants in Utah, the benefits of simulation far outweighed the number of drawbacks. The opposite was true in Ecuador, where participants expressed more drawbacks than benefits. Some of this discrepancy may be attributed to the language barrier in this study, but it also seems the higher the fidelity of simulation used, the more beneficial it is to students. Simulation in Ecuador has not reached the level of technology or use that is seen in the United States. Due to the low fidelity simulation available in Ecuador, most use appears to be skill-related rather than scenario or situation based. The latter does occasionally exist, and in such cases was found to aid participants in “Putting it Together.” However, as simulation advances and grows in Ecuador, the Ecuadorian nurse may experience similar benefits of better preparation and increased critical thinking development.

Simulation appeared to be an excellent preparatory step in the journey to becoming a nurse for participants in Utah, teaching all aspects of critical thinking in Lasater’s Clinical Judgment Rubric (Lasater, 2007b): noticing deviations from expected patterns, interpreting and prioritizing data, helping to build comfort and confidence in demeanor, communicating effectively and appropriately, being skillful and appropriately intervening, and reflecting and evaluating to improve one’s self and performance. Most growth in these areas was attributed to use of a high fidelity simulator, suggesting that the higher fidelity simulation is more beneficial to critical thinking and clinical judgment than lower fidelity simulation.

Simulation provides a route to apply knowledge and skills learned in the classroom and to build confidence and familiarity, thus preparing students and new nurse graduates to enter the clinical setting with real patients. However, simulation must be used effectively to create such results. As expressed by participants, the higher the fidelity, where students can observe for themselves deviations and problems rather than just be told about them, the more beneficial the experience. Also, a facilitator must not be overly involved, informing students of tasks or data before students have a chance to make discoveries for themselves. Instead, a facilitator must be present, encouraging when required, supervising, and asking appropriate questions to turn the student minds toward critical thinking. Simulation can be used for an array of tasks, from simple skills to advanced situations, such as caring for a simulation patient experiencing cardiac arrest or major trauma. Practicing skills alone does build competence and confidence as far as the skill goes, but the most beneficial experiences with simulation are those using problem-based scenarios, which incorporate both necessary skills and essential critical thinking and best empowers and prepares the student nurse.

It is noteworthy that even the highest fidelity simulator cannot substitute for all real patient interactions in nursing education. As expressed by participants, experiences with real patients are necessary due to critical thinking development that occurs in a hospital setting with real patients and real time. Simulation is also limited to the amount of exposure it can offer to possible situations encountered in a clinical setting. Therefore, time spent in simulation labs must be used as an adjunct to clinical settings in a hospital and not as a replacement.
This study included limited exposure to nurse education programs and current working licensed nurses in Ecuador. It would be beneficial in the future to more fully explore the role of simulation in this country and others throughout Latin America and the relationship with the role of the nurse. As more simulation labs are established using high fidelity simulators in Latin America, it may be interesting to study the change this produces in the Latin American nurse.

References

Childs, J. C., & Sepples, S. (2006). Clinical teaching by simulation: Lessons learned from a complex patient care scenario. Nursing Education Perspectives, 27(3), 154-158.

de Leon Siantz, M. L., & Malvárez, S. (2008). Migration of nurses: a Latin American perspective. Online Journal of Issues in Nursing, 13(2), Article 2. Retrieved September 18, 2009 from http://www.nursingworld.org.../LatinAmericanPerspective.aspx.

Jeffries, P. R. (Ed.). (2007). Simulation in nursing education: From conceptualization to evaluation. New York: National League for Nursing.

Lasater, K. (2007a). High fidelity simulation and the development of clinical judgment: Students’ experiences. Journal of Nursing Education, 46(6), 269-276.

Lasater, K. (2007b). Clinical judgment development: Using simulation to create an assessment rubric. Journal of Nursing Education, 46(11), 496-503.

National League for Nursing. (n.d.). Simulation innovation resource center glossary. Retrieved September 14, 2009 from http://sirc.nln.org/mod/glossary/view.php?id=183.

Malvarez, S., & Castrillon Agudelo, M.C. (2005). Overview of the nursing workforce in Latin America, Issue paper 6. Human Resources Development Series, No. 39 Washington DC: Pan American Health Organization.

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

United States Department of Health and Human Services, Health Resources and Services Administration. (2004). What is behind HRSA’s projected supply, demand, and shortage of registered nurses? Retrieved March 1, 2008 from http://bhpr.hrsa.gov/healthworkforce/reports/behindrnprojections/index.htm


 


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