URC

Nursing Students’ Perceptions of Learning Outcomes throughout Simulation Experiences

Christina Hunter
Patricia K. Ravert*

Brigham Young University


Abstract

The purpose of this study was to determine undergraduate nursing students’ perceptions regarding learning outcomes developed during simulation experience throughout the nursing program. Students from four different semesters completed surveys following their simulation experience to report their perceptions of learning outcomes (improving communication, increasing nursing skills, understanding classroom material, developing critical thinking, and facilitating teamwork). Results indicated that each semester, students rated increasing nursing skills and developing critical thinking as two of the top three learning outcomes obtained during simulation experiences. Students perceived that developing the learning outcome of facilitating teamwork increased more in later semesters. Improving communication and understanding classroom material were not rated as frequently.

Keywords: simulation, nurse education, learning outcomes, student perceptions

“Simulation is the artificial representation of a phenomenon or activity” (Larew, Lessan, Spunt, Foster, & Covington, 2006, p. 17).  Simulation has been used since the 1930s to train individuals in aviation and the military (Broussard, Myers, & Lemoine, 2009). Commercial aviation, nuclear power production, and the military are some of the industries that continue to use simulation for training. Risks are associated with these industries, however safety and reliability are expected. Similar to the public’s demand for safety in aviation is the demand for safety in healthcare (Gaba, 2004). The healthcare industry has also utilized simulation in order to ensure safety and reliability, despite the associated risks involved. Medical errors, patient safety, professional competency, and new technologies are some of the factors that have contributed to the rise of simulation in medical education (Issenberg, McGaghie, Petrusa, Gordon, & Scalese, 2005). Simulation, using safe structured learning experiences, can be offered consistently to all students in order to meet learning outcomes (Larew et al., 2006). What are students’ perceptions regarding learning outcomes in the simulation experiences in a nursing program?

Brief Literature Review

Many studies have found that simulation experiences facilitate learning. A Best Evidence Medical Education (BEME) systematic review of 109 journal articles concluded that simulations facilitate learning (Issenberg et al., 2005). Nursing students began perfecting their physical assessment skills on a simulated model of a torso in the late 1950s. In the 1960s, a simulator with heart and lungs helped nursing students to distinguish between normal and abnormal cardiopulmonary findings (Pacsi, 2009). Currently, a variety of simulations are incorporated into nursing education programs nationwide. Advanced models can simulate reality-based scenarios such as an intensive care unit clinical setting where simple models include equipment to practice skills such as intravenous access. Simulation can expose students to events that will be part of their healthcare practice in the future but may not be available in the clinical setting (Broussard et al., 2009).

Exposure to events is one of the many dimensions of simulation that can be useful in nursing education. For example, the aims and purposes of the simulation activity can vary along with the simulated patient’s age, the nursing domain, the extent of direct participation, and the technology available (Gaba, 2004). A controlled environment is an additional benefit of simulation. Students become active participants and can make errors without adverse consequences (Issenberg et al., 2005). Patient safety is improved as students learn from the mistakes they make (Broussard et al., 2009). Students are able to practice and experiment with various approaches during simulation without harming patients. Students can choose the approach that works well for them and have confidence in their approach when they work with an actual patient (Simpson, 2002). Simulations transition theoretical knowledge into practice and are highly valued by medical students (Weller, 2004).

Nursing students obtain knowledge through multiple learning strategies. Simulations are adaptable for multiple learning strategies (Issenberg et al., 2005). A study found that both students with a strong preference for solitary learning and students with a strong preference for social learning were satisfied with simulation experiences. The social learners compared, listened, networked, and interacted with others while the solitary learners observed the actions of others, reflected, and worked at their own pace (Fountain & Alfred, 2009).

Simulations benefit students with multiple learning styles and contribute to achieving educational program goals. Patricia Benner (1984) stated, “The goal of educational programs is to provide a broad base of clinical theory and skill that will provide the nurse with maximum flexibility and scope of practice after graduation” (p. 185). Simulation experiences with clearly stated goals and outcomes achieve Benner’s definition of an educational goal (Issenberg et al., 2005). Identified learning outcomes involving simulation include a) improving communication, b) increasing nursing skills, c) understanding classroom material, d) developing critical thinking, and e) facilitating teamwork.

Improving Communication

Benner (1984) stated that the ability to communicate with members of the healthcare team is a characteristic of an expert nurse. Simulation is useful in improving communication with patients and the healthcare team (Gaba, 2004). In a more recent study, Kameg, Howard, Clochesy, Mitchell, and Suresky (2010) concluded that simulations helped students learn communication techniques. In addition, students perceived that their communication improved, and simulations increased their confidence in communication. “Communication is a critical component of nursing education as well as a necessity in maintaining patient safety” (Kameg et al., p. 315).  In summary, communication is a non-technical nursing skill that can be improved using simulation.

Increasing Nursing Skills

Early use of simulation in nursing education included teaching psychomotor skills and expanded to include the practice of skills within specialized areas (Larew et al., 2006). Nursing students have fewer opportunities to practice skills in clinical situations because of shorter patient stays and downsizing of hospitals (Simpson, 2002). Practicing skills contributes to better skill performance (Issenberg et al., 2005). Also, students that practice skills using simulation have more confidence in the clinical setting (Simpson, 2002). Cognitive, psychomotor, and affective skills can be taught and practiced using simulation (Broussard et al., 2009; Gaba, 2004).

Understanding Classroom Material

Skills are part of the material taught in the classroom. Students reported increased understanding of course material as a result of participating in clinical simulation scenarios. Classroom material can be reinforced and clarified using simulation (Comer, 2005). Increasing the understanding of classroom content is a benefit of incorporating simulation into nursing programs. In addition, when students understand classroom material, they have the opportunity to synthesize knowledge from other sources (Broussard et al., 2009).

Developing Critical Thinking

Synthesizing knowledge is one of the steps of critical thinking. Simulation is one of the best ways to help students develop critical thinking (Broussard et al., 2009; Larew et al., 2006). Unlike the classroom setting where students learn passively, simulation allows students to think spontaneously and actively (Broussard et al.).  Nurses make many decisions each day and often these decisions need to be made quickly. Simulations allow students to make decisions independently and take risks. This process helps to gain the critical thinking skills needed in their profession (Simpson, 2002).  Weller (2004) found students value the opportunity to apply theoretical knowledge in a safe and realistic setting during simulations in order to develop a systematic approach to solving problems.

Facilitating Teamwork

Problem solving can effectively be done in teams. Weller (2004) also found the students value the opportunity to develop teamwork skills during simulation. Collaborating with team members is also a characteristic of an expert nurse according to Benner (1984). Collaborative practice, also known as teamwork, is a higher level nursing function that simulation allows students to practice (Gaba, 2004; Larew et al.). Within the team, nursing students have the opportunity to assume leadership roles during simulation (Broussard et al., 2009). It is important to facilitate teamwork because empirical evidence finds individual performance does not provide optimum safety. Nursing students learn teamwork during simulations by functioning as a single discipline team. Multidisciplinary healthcare teams can also benefit from simulation experiences (Gaba, 2004).

Students’ Experience Level

Facilitating teamwork, developing critical thinking, understanding classroom material, increasing nursing skills, and improving communication are identified learning outcomes associated with simulations. McGaghie, Issenberg, Petrusa, and Scalese (2006) reviewed thirty-two research studies and found repetitive practice with simulations is associated with improved learning outcomes. This applies to all levels of learners (McGaghie et al.). Beginner learners “operate on abstract principles, formal models, and theories to get into the situation in a way that they can learn safely and efficiently” while experiential learners “pose and test questions in real situations that deviate from expectations based upon theory and principles” (Benner, 1984). The type of simulation can be adjusted to meet the level of nursing students (Gaba, 2006; Issenberg et al., 2005). Nursing students can achieve learning outcomes despite the constraint of their experience level during simulations (Bambini, Washburn, & Perkins, 2009; Larew et al., 2006).

There is limited research on the correlation between simulation and effect on student learning outcomes (Kameg et al., 2010). Bambini et al. (2009) suggest using the framework of self-efficacy to determine the effectiveness of simulations on learning outcomes. Self-efficacy is a student’s perception of how well he or she achieved the learning outcomes. Bambini et al. conducted a study that evaluated the increase of self-efficacy of beginning nursing students. The learning outcomes of communication, confidence in skills, and improved critical thinking emerged as themes. More research is needed on learning outcomes involving simulation across different educational levels of nursing students (Bambini et al.; Gaba, 2004). The purpose of this study is to determine students’ perceptions regarding learning outcomes and their development through the simulation experiences in the nursing program.

Methodology

Description of Subjects

Subjects included undergraduate baccalaureate nursing students, at a private university in the mountain west in the second through fifth semester of the nursing program during winter semester 2010, who participated in simulations. These students were asked to participate in this study; after giving consent, students completed a survey at the end of their simulation experience.

Instruments

The Institutional Review Board approved a 6-item survey that allows students to report their demographic information and perceptions of learning outcomes. This survey was created by the authors and consisted of five questions involving demographics, rating of learning outcomes, and one open-ended question (see Appendix). Demographics included gender, year in school, age, ethnicity, and which nursing course involved the simulations. Learning outcomes consisted of improving communication, increasing nursing skills, understanding classroom material, developing critical thinking, and facilitating teamwork. After participating in assigned simulations, students completed the survey by selecting the learning outcomes, which they perceived improved or developed through the simulation experience.

Procedure

A descriptive quantitative method was used in this study. Undergraduate baccalaureate nursing students, in the second through fifth semester of the nursing program during winter semester 2010, participated in simulations. Second semester classes included nursing fundamentals simulations, third semester classes included medical-surgical nursing simulations, fourth semester classes included labor and delivery and pediatric simulations, and fifth semester classes included intensive care unit simulations. Students were notified by classroom announcement after the simulation experiences were completed. After consenting, students reported demographic data and completed a survey to report their perceptions of learning outcomes (improving communication, increasing nursing skills, understanding classroom material, developing critical thinking, and facilitating teamwork). Students rated their perceptions of the top three learning outcomes (1 being the highest) that improved/developed through the simulation experience.         

Data Analysis

Quantitative data from the ranked learning outcomes were scored. The highest ranked learning outcome received three points, the second ranked outcome received two points, the third ranked outcome received one point, and unranked outcomes received no points. The total possible points divided the sum of points for each outcome determined the rankings. This percentage represents students’ perceptions of learning outcomes achieved. Demographic data were entered into SPSS for analysis. Qualitative data from written comments were analyzed for descriptive categories using inductive and emergent processes. Descriptive categories were identified and relevant quotes to each category were chosen to illustrate the content.

Results

The 162 respondents represented all classes in the nursing program: sophomore (28.6%), junior (38.5%), and senior (32.9%). The majority was female (92%) and Caucasian (94.4%), with Asian (2.5%), Hispanic (0.6%), and other (2.5%). Overall, students ranked obtaining the learning outcomes of developing critical thinking and increasing nursing skills the highest (see Figure 1). Three general themes were identified in the qualitative comments. The first theme was critical thinking. Students indicated they improved in their ability to analyze a situation, make connections, and apply their knowledge. The second theme was increase or improvement in nursing skills. Participants stated they were able to solidify proper techniques through practicing nursing skills during simulations. The third theme was confidence. Students reported feeling more comfortable with their knowledge, skills, and understanding of the nursing process in different situations. In addition to overall rankings and themes, each semester varied in which outcomes were obtained.


Figure 1. Overall Results (n=162)

Nursing Fundamentals Simulations

Students worked through four case studies during nursing fundamentals simulations. The highest ranked learning outcomes were increasing nursing skills and developing critical thinking (see Figure 2). Nursing fundamental students stated their nursing skills increased because they were able to physically perform skills in a safe environment during simulations. Students also stated that critical thinking demonstrated in class was reinforced during simulations because they had to apply their knowledge. Facilitating teamwork was the lowest ranked learning outcome.


Figure 2. Nursing Fundamental Results (n=57)

Medical-Surgical Simulations

Students participated in five scenarios during medical-surgical nursing simulations. The highest ranked learning outcome was developing critical thinking (see Figure 3). Medical-surgical nursing students reported an improvement in critical thinking because they were able to think through high-pressure situations during simulations. As a result, they were able to analyze information, prioritize, and make informed decisions. Understanding classroom material was the lowest ranked learning outcome for this semester.


Figure 3. Medical-Surgical Results (n=55)

Labor and Delivery and Pediatric Simulations

Students participated in four scenarios involving labor and delivery and pediatric nursing simulations. Learning outcome results were similar to medical-surgical simulation results with critical thinking being the highest ranked outcome (see Figure 4). Critical thinking was also a theme with students from this semester stating they learned to assess a situation, think through it, and act. Another theme that emerged was working as a team and becoming a leader. Students described learning that they could not do everything by themselves. They also learned about delegating tasks to others. Understanding classroom material and improving communication were the lowest ranked outcomes for this learning outcome.

 
Figure 4. Labor and Delivery and Pediatric Results (n=25)

Intensive Care Unit Simulations

Students participated in four scenarios involving intensive care unit simulations. Developing critical thinking and facilitating teamwork were the highest ranked learning outcomes (see Figure 5). Students noticed an improvement in their critical thinking because they were more aware of situations and what interventions to implement. Students also stated they were able to better fulfill certain roles and work as a team. Students felt comfortable asking for help and helping others. Improving communication was the lowest ranked learning outcome.

 
Figure 5. Intensive Care Unit Results (n=23)

Discussion

Students rated increasing nursing skills and developing critical thinking as two of the top three learning outcomes obtained during simulation experiences. Developing critical thinking was the highest ranked outcome overall. This study demonstrated that simulation experiences are one of the best ways to help students develop critical thinking (Broussard et al., 2009; Larew et al., 2006).

Nursing fundamental students most frequently rated the learning outcome of increasing nursing skills whereas students most frequently rated the outcome of developing critical thinking in all other simulation experiences. In fact, the highest ranked learning outcome of this study was increasing nursing skills, which received 91 percent of the points by nursing fundamental students. Nursing fundamental students are novice students that are focused on improving their own nursing skills and their personal development as a nurse. After students gain confidence in their own skill development, they are better able to think critically and become an effective team member.

Students rated the outcome of facilitating teamwork higher in the semesters following nursing fundamentals. In fact, the learning outcome of facilitating teamwork was the only outcome that was consistently ranked higher throughout the simulation experiences (see Figure 6). This study determined that as students near the end of the nursing program, the learning outcome of facilitating teamwork was achieved more frequently each semester.


Figure 6. Teamwork Rankings

Communication and increasing the understanding of classroom material were not rated as frequently as any of the other learning outcomes throughout the simulation experiences. If the learning outcome for the simulation experience includes improving communication or increasing the understanding of classroom material, the experiences may need to be revised for such emphasis. For example, if improving communication was the objective, having students call the physician in each simulation using SBAR would emphasize this objective. All learning outcomes for simulation experiences should be evaluated closely and experiences revised as necessary.

Limitations of this study include participant group variability and small sample size. Participants had slightly different simulation experiences because of group dynamics. Each group of students had different questions, responses, and actions during each simulation. Also, the sample of this study does not adequately represent the population. Participants were not randomly selected and only nursing students from one university were included in this study.

Further research should be conducted using a larger population with students from multiple nursing programs. Further research could also be conducted using other learning outcomes. For example, students’ perceptions of their competency of a specific skill performed during simulations could be evaluated.

Conclusion

Simulations are effective in student learning. Improving communication, increasing nursing skills, understanding classroom material, developing critical thinking, and facilitating teamwork are learning outcomes that can be obtained through simulation experiences (Bambini et al., 2009; Broussard et al., 2009; Comer, 2005; Gaba, 2004; Issenberg et al., 2005; Kameg et al., 2010; Larew et al., 2006; McGaghie et al., 2006; Simpson, 2002; Weller, 2004).  Each semester, students rated increasing nursing skills and developing critical thinking as two of the top three learning outcomes obtained during simulation experiences. Students perceived that achieving the learning outcome of facilitating teamwork occurred more in later semesters. If the learning outcome for the simulation experience includes improving communication or increasing the understanding of classroom material, the experiences may need to be revised for such emphasis. Although this study adds information to research on simulations and learning outcomes, further research is needed on a larger sample size and other learning outcomes.

References

Bambini, D., Washburn, J., & Perkins, R. (2009). Outcomes of clinical simulation for novice nursing students: Communication, confidence, clinical judgment. Nursing Education Perspectives, 30(2), 79-82.

Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, CA: Addison-Wesley Publishing Company.

Broussard, L., Myers, R., & Lemoine, J. (2009). Preparing pediatric nurses: The role of simulation based learning. Issues in Comprehensive Pediatric Nursing, 32, 4-15. doi:10.1080/01460860802610178

Comer, S. K. (2005). Patient care simulation: Role playing to enhance clinical understanding. Nursing Education Perspectives, 26(6), 357-361.

Fountain, R. A. & Alfred, D. (2009). Student satisfaction with high-fidelity simulation: Does it correlate with learning styles?. Nursing Education Perspectives, 30(2), 96-98.

Gaba, D. M. (2004). The future vision of simulation in health care. Quality & Safety in Health Care, 13, 2-10.

Issenberg, S. B., McGaghie, W. C., Petrusa, E. R., Gordon, D.G., & Scalese, R. J. (2005). Features and uses of high-fidelity medical simulations that lead to effective learning: A BEME systematic review. Medical Teacher, 27(1), 10-28.

Kameg, K., Howard, V. M., Clochesy, J. M. Mitchell, A. M. & Suresky, J. M. (2010). The impact of high fidelity human simulation on self-efficacy of communication skills. Issues In Mental Health Nursing, 31(5), 315-323.

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

McGaghie, W. C., Issenberg, S. B., Petrusa, E. R., & Scalese, R. J. (2006). Effect of practice on standardized learning outcomes in simulation-based medical education. Medical Education, 40(1), 792-797.

Pacsi, A. L. (2008). Human simulators in nursing education. Journal of the New York State Nurses Association, 39(2), 8-11.

Simpson, R. L. (2002). The virtual reality revolution: Technology changes nursing education. Nursing Management, 33(9), 14.

Weller, J. M. (2004). Simulation in undergraduate medical education: Bridging the gap between theory and practice. Medical Education, 38(1), 32-38.


 

Appendix

 

Learning Outcomes Survey

Which gender are you?

  1. Male
  2. Female

How many years have you been at BYU or in college?

  1. One
  2. Two
  3. Three
  4. Four
  5. Five or more

Which ethnicity do you consider yourself?

  1. Caucasian
  2. Asian
  3. Hispanic
  4. Other ________

Which nursing class did you most recently participate in involving simulation experiences?

  1. Nurs 295 (Fundamentals)
  2. Nurs 330 (Med-Surg)
  3. Nurs 340 and Nurs 360 (Labor and Delivery and Pediatrics)
  4. Nurs 470 (ICU)

Of the following learning outcomes, please rate the top three (3) outcomes obtained during the simulation experiences with number one (1) being the outcome which rates the highest

___Improving Communication

  Talking to the patient, calling the doctor, etc

___Increasing Nursing Skills

  Assessments, administering medication, documentation, etc

___Understanding Classroom Material

  Clarification of what was discussed or presented in class

___Developing Critical Thinking

Prioritization, developing care plans, understanding the disease process and how it relates to patient care, etc

___Facilitating Teamwork

  Working with other members of the healthcare team including other students

What do you feel you have improved most in and why?

 


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