Simulation: Making it Real For Nursing Students

The IOM report on nursing work environments recommends simulation as a method to support nurses in the ongoing acquisition of knowledge and skills.

Simulation has come a long way from Mrs. Chase or Resuscitation Annie – lifesize manikins that were also known as partial task trainers or demonstration dolls. Nursing students could practice simple procedures such as turning patients in bed, giving them a bath and putting them on bedpans. The students then practiced inserting IV lines and giving injections on each other.

Technological advances have changed the simulation experience for nursing students. Today's simulation laboratory creates a realistic patient care environment. High-fidelity, full-body manikins are interactive and lifelike. They have heart and lung sounds and can sweat, breathe, bleed, urinate, seize, shake and even have babies! Their lips can turn blue, the eyes blink and pupils change. They can be hooked up to a monitor and have IVs inserted. Vital signs change in response to student interactions. In the simulation laboratory, real-life scenarios are created and students can develop and practice their nursing skills in an environment that doesn't endanger patients. Instructors and students then meet for a debriefing to review the simulation, decisions made and areas for improvement. These simulations even include manikins that are ethnically diverse – exposing students to delivery of culturally competent care.

"The goal of simulation here at UCLA is to send students out into the clinical setting more prepared and better able to tackle the wide variety of situations they may encounter as nurses," says Mary Ann Shinnick, director of Simulation. "It is a great teaching method which mimics the clinical setting more than any teaching method we have ever had. This is especially important as clinical rotation sites in hospitals have become difficult to find."

During clinical experiences, students manage a limited number of patients under very close supervision in a variety of real-world healthcare environments. While this offers the opportunity to interact with real patients, depending on the patient census, participation in challenging, high-risk clinical work often is matter of timing and circumstance. Thus, a student's clinical experience can vary and in critical situations (i.e., a patient with chest pain), the student is often observing and not managing the care. Oftentimes, their first exposure to a particular complex case occurs after graduation.

"In simulation, the students are the nurse," adds Shinnick. "In simulation, we can create and repeat identical clinical situations such that all students have the same experience, something that cannot occur in a hospital clinical experience. For example, we developed a leadership simulation where a 5-bed medical unit is set up with interactive manikins, each with a specific medical diagnosis, role players, patient charts and family

members at the bedside. The goal of this simulation is to re-create the events of a morning shift on a medical surgical floor such that the senior students can practice leadership, communication, delegation, teamwork, and prioritization. It many cases, it acts as a "reality check" for what it feels like to actually be an RN in charge of more than 1-2 patients."

Can Simulation Be Used As a Substitute for Clinical Hours?

This past August, a study by the National Council of State Boards of Nursing (NCSBN) concluded that substituting high quality simulation experiences for up to half of traditional clinical hours produces comparable end of program educational outcomes to those students whose experiences do not include more than 10% of clinical time in simulation.

This study included nursing students (666) from 10 prelicensure programs across the U.S. who were placed into one of three study groups:

  • Control group (traditional clinical hours where up to 10 percent of clinical time was allowed in simulation)
  • 25 percent group: 25% of the required clinical hours were done in simulation instead
  • 50 percent group: 50% of the required clinical hours were done in simulation instead

The study began in the 2011 fall semester with the first clinical nursing course and continued throughout the core clinical courses to graduation in May 2013. Students were assessed and groups compared in several areas, including clinical competency, state licensing scores (NCLEX), national standardized knowledge testing and self-evaluation of how their learning needs were met in both environments. .

The study found that up to 50 percent simulation was effectively substituted for traditional clinical experience in all core courses across the prelicensure nursing curriculum. Additionally, the use of up to 50 percent simulation did not affect NCLEX pass rates.

Study participants were also followed into their first six months of clinical practice. The study found that there were no meaningful differences between the groups in critical thinking, clinical competency and overall readiness for practice as rated by managers at six weeks, three months and six months after working in a clinical position. These long-awaited results reinforce what educators using simulation have long believed. State Boards of Nursing are now taxed with determining appropriateness of increasing the current limits of simulation as a teaching method in lieu of clinical (California is at 25%).

A positive experience

Students love the simulation environment as well and the feedback is very positive.

"In the hospital, things happen right away and I need to respond right away," said one former student. "The great thing about simulation is that it allows me to practice how I deal with things."

Other student comments from simulation evaluations included:

  • "I love the opportunity of no judgment and safety of a learning environment"
  • "Thank you for filling the gap between our class learning and real life"
  •  "Sim lab really gave me preparation in terms of starting to put myself in the mindset of a nurse"
  • "Simulation helps us feel the responsibility of a patient's case and get used to prioritizing and trying to figure out what's going on with the patient. It helps us work through the logistics too."

Creating The Future of Simulation

In the past few years, a number of issues have risen that are driving the expanded use of simulation: more programs competing for limited clinical sites, faculty shortages, facilities not granting students access to electronic medical records, pediatric sites not allowing students to administer medications or even do vital signs and patient safety initiatives that decrease the number of students allowed on a patient unit or restrict their activity to observing care.

"Simulation is a viable option for allowing students to expand their experiences"

Other uses for the Simulation Laboratory include:

  • Research. The School has done more simulation research than most nursing schools. In the past four years, six papers have been published showcasing the benefits and opportunities for simulation training with new research being done continuously.
  • Skills assessment. This Fall, the school is implementing skills based testing on all lab courses- known as OSCE's (Objective, Structured Clinical Exams), in which students apply clinical and theoretical knowledge on standardized tasks. "Medical schools have been doing this for decades, and we are among the first nursing schools to implement this throughout the prelicensure nursing program."

Developing a simulation lab that can meet the changing healthcare environment and provide our students with the optimal experiences is a major investment. Manikins can cost upwards of $100,000 and need to be updated every five years due to wear and tear and to keep up with changes in technology.

"Our dream would be to have a nursing full-service simulation center that would include patient rooms that could replicate a variety of clinical settings, a central control room and debriefing areas," said Linda Sarna, acting dean. "This would allow us to provide

our students with the real-life practice and execution of the skills they will need to safeguard patient's health in every setting."

Watch this video of how we are using simulation in our nursing education.