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,
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
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.
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,
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.
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.
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.
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.
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.
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
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)
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
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)
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.
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.
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,
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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.
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Learning Outcomes Survey
Which gender are you?
How many years have you been at BYU or in college?
- Five or more
Which ethnicity do you consider yourself?
- Other ________
Which nursing class did you most recently participate in involving simulation experiences?
- Nurs 295 (Fundamentals)
- Nurs 330 (Med-Surg)
- Nurs 340 and Nurs 360 (Labor and Delivery and Pediatrics)
- 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
to the patient, calling the doctor, etc
___Increasing Nursing Skills
administering medication, documentation, etc
___Understanding Classroom Material
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
with other members of the healthcare team including other students
What do you feel you have improved most in and why?