NCSBN RESEARCH BRIEF

Volume 40 | June 2009

The Effect of
High-Fidelity
Simulation on
Nursing Students
Knowledge and
Performance:
A Pilot Study
Report of Findings from

The Effect of High-Fidelity Simulation
on Nursing Students Knowledge and
Performance: A Pilot Study
Principal Investigators
Frank D. Hicks, PhD, RN, Rush University College of Nursing, Chicago, IL
Lola Coke, PhD, RN, Rush University College of Nursing, Chicago, IL
Suling Li, PhD, RN, National Council of State Boards of Nursing, Chicago, IL
National Council of State Boards of Nursing, Inc. (NCSBN

)
National Council of State Boards of Nursing, Inc. (NCSBN) | 2009
ii REPORT OF FINDINGS FROM THE EFFECT OF HIGH-FIDELITY SIMULATION ON NURSING STUDENTS
KNOWLEDGE AND PERFORMANCE: A PILOT STUDY
Mission Statement
The National Council of State Boards of Nursing, composed of member boards, provides leadership to advance regulatory
excellence for public protection.
Copyright 2009 National Council of State Boards of Nursing, Inc. (NCSBN

)
All rights reserved. NCSBN

, NCLEX

, NCLEX-RN

, NCLEX-PN

and TERCAP

are registered trademarks of NCSBN and

this document may not be used, reproduced or disseminated to any third party without written permission from NCSBN.
Permission is granted to boards of nursing to use or reproduce all or parts of this document for licensure related purposes
only. Nonprot education programs have permission to use or reproduce all or parts of this document for educational
purposes only. Use or reproduction of this document for commercial or for-prot use is strictly prohibited. Any authorized
reproduction of this document shall display the notice: Copyright by the National Council of State Boards of Nursing,
Inc. All rights reserved. Or, if a portion of the document is reproduced or incorporated in other materials, such written
materials shall include the following credit: Portions copyrighted by the National Council of State Boards of Nursing,
Inc. All rights reserved.
Address inquiries in writing to NCSBN Permissions, 111 E. Wacker Drive, Suite 2900, Chicago, IL 60601-4277. Suggested
Citation: National Council of State Boards of Nursing. (2009). Report of Findings from The Effect of High-Fidelity
Simulation on Nursing Students Knowledge and Performance: A Pilot Study. (Research Brief Vol. 40). Chicago: Author.
Printed in the United States of America
ISBN# 978-0-9822456-5-1
National Council of State Boards of Nursing, Inc. (NCSBN) | 2009
iii
TABLE OF CONTENTS
List of Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
I. Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Advantages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Disadvantages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Review of the Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Variables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
II. Study Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
III. Research Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
IV. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Design and Sampling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Simulation only . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Simulation and clinical . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Clinical only . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Outcome Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Knowledge Acquisition and Retention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Clinical Performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Faculty Review of Videotaped Student Performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Self-condence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Protection of Human Research Subjects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Data Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
V. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Demographics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Knowledge Acquisition and Retention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Clinical Performance Assessed with Standardized Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Self-condence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Course Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
VI. Limitations of the Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
VII. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
VIII. Avenues of Future Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
IX. References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Appendix A: Chest Pain Scenario . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Appendix B: Shortness of Breath Scenario . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Appendix C: Level of Consciousness Scenario . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Appendix D: Self-condence Scale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
TABLE OF CONTENTS
National Council of State Boards of Nursing, Inc. (NCSBN) | 2009
iv
LIST OF TABLES
LIST OF TABLES
Table 1. Demographics of Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Table 2. Written Exam Scores Before and After Simulation/Clinical Experiences . . . . . . . . . . . . . . . . 11
Table 3. Clinical Performance on Three Patient Care Scenarios Portrayed by
Standardized Patients: Tape Review Checklist Rating . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Table 4. Total Time to Complete Three Patient Care Scenarios Portrayed by
Standardized Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Table 5. Dimensions of Perceived Condence Before and After
Simulation/Clinical Experiences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Table 6. Perceived Condence Before and After Simulation/Clinical Experiences . . . . . . . . . . . . . . . 14
Table 7. Perceived Clinical Experience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Table 8. Perceived Simulation Experience (n=37) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Table 9. Student Learning Based on Self-Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
National Council of State Boards of Nursing, Inc. (NCSBN) | 2009
v
ACKNOWLEDGMENTS
ACKNOWLEDGMENTS
This study would not have been possible without the support provided by the Rush University College of
Nursing (RUCON) and Rush University Simulation Laboratory (RUSL). The authors acknowledge the contri-
butions of the involved faculty, staff and students who expended time and energy to help implement the
study protocol. Specically, the authors acknowledge the following individuals for their valuable contribu-
tions to the study: Marcia Bosek, PhD, RN, former associate professor, RUCON, Chris MacNeal, simulation
coordinator, RUCON and Lynn Richter, MSN, RN, APRN-BC, assistant professor, RUCON.
The authors also gratefully acknowledge Nancy Spector, PhD, RN, NCSBN, director, innovations, Kevin
Kenward, PhD, NCSBN, director, research, Maryann Alexander, PhD, RN, NCSBN, chief ofcer, nursing
regulation, and Mary E. Doherty, JD, BSN, RN, NCSBN, associate, nursing regulation for their support and
valuable feedback to the project, and Richard Smiley, MS, NCSBN, statistician, research, for his help with
the statistical analysis.
National Council of State Boards of Nursing, Inc. (NCSBN) | 2009
1
INTRODUCTION
INTRODUCTION
Simulation, the art and science of recreating a
clinical scenario in an articial setting, has been an
important aspect of nursing program curriculums for
decades (Gomez and Gomez, 1987). As an adjunct
to clinical experience, simulation has allowed
deliberate practice in a controlled environment.
Students are able to practice a procedure prior to
performance on a live patient. The value of this is
unquestionable. Recently, however, high-delity
simulation, with the increased level of sophistication
and realism it brings to the laboratory setting, has
elicited the possibility of simulation being used as
a substitute for actual clinical experience. This study
explores that concept.
High-delity simulation refers to structured student
learning experiences with the use of a technological-
ly advanced computerized mannequin, the Human
Patient Simulator (HPS). HPS is anatomically precise
and reproduces physiologic responses. Students
are administered sequential decision-making events
within an environment that mimics a clinical setting.
Instructors can control the mannequins responses
and the HPS can respond to interventions provided
by the student (Gilley, 1990; Graedler, 1992; Lasater,
2007). Gaba (2004) describes simulation as a strat-
egy not a technology, to mirror, anticipate, or
amplify real situations with guided experiences in a
fully interactive way.
The subject of simulation and its uses in prelicensure
education is of prime signicance to regulators.
From a regulatory perspective, simulation offers
advantages. It harbors patients from unnecessary
risk and/or discomfort, thus providing an element
of public protection. The increased opportunities to
encounter infrequent and atypical clinical problems
may better prepare new graduates for transition
into the workforce. It may also offer an alternative
for nursing programs dealing with a limited number
of clinical sites or clinical sites that have inadequate
learning opportunities. A goal of regulation is to
make certain that the future workforce has safe
and competent nurses. Thus, regulators are also
interested in ensuring that nursing students are pro-
vided with optimal education experiences. Despite
its obvious benets, there is a paucity of evidence
regarding the efcacy of high-delity simulation
as a teaching method beyond the acquisition of
psychomotor skills.
How well simulation assists students in acquir-
ing and integrating knowledge, skills and critical
thinking, and how it fares when compared to tradi-
tional clinical/real patient encounters, are a few of
the questions being asked by both educators and
regulators alike. It is unknown as to what degree
simulation learning is transferable to the clinical
area or if simulation learning is as effective as actual
clinical experience in developing professional judg-
ment. There is also little evidence demonstrating
how well it assists in building condence. Because
of these questions and the lack of evidence to
answer them, it is unknown as to what degree high-
delity simulation would be an appropriate and
suitable substitute for real clinical experiences now
required by state regulations for nursing programs.
As the rst step in addressing these questions, it is
important to determine if high-delity simulation
provides an effective learning strategy equivalent to
clinical experiences.
National Council of State Boards of Nursing, Inc. (NCSBN) | 2009
2
BACKGROUND
BACKGROUND
Documented throughout the literature are the
advantages and disadvantages of high-delity sim-
ulation. The following list summarizes the pros and
cons of this methodology.
Advantages
No direct risk to patients. Simulation offers
opportunities to practice rare and critical
events in a safe and controlled environment,
affording unlimited practice without risk to
patients (Gilley, 1990; Graedler, 1992; Maran
and Glavin, 2003, Decker, et al., 2008).
The potential to increase the speed of acqui-
sition of clinical skills to a dened level of
competence by allowing the opportunity for
repetitive practice at the learners own pace
(Maran and Glavin, 2003).
Team training. Scenario themes can focus on
understanding team collaboration and com-
munication (Ellis, et al., 2008; Lasater, 2007).
Can allow a standardized curriculum to be
developed as the same exact scenarios can
be presented to all learners. Simulation
reduces training variability and increases
standardization. With simulation, faculty can
guarantee the same experience for every
student (Maran and Glavin, 2003).
Reective learning by facilitated debrieng
of scenarios and video feedback (Lederman,
1992; Gilley, 1990; Hertel and Millis, 2002;
Gaba, 2000).
Potential to decrease the number and effect
of errors through crisis resource management
(CRM) training (Ziv, et al., 2003).
Disadvantages
Equipment delity. Fidelity is the degree to
which the simulator itself replicates real-
ity. A major limitation of simulation is the
delity; no matter how high the delity is, it
is not real. It is often impossible to imitate
actual physiological signs or symptoms. For
example, it is impossible to display crackles
in the lung, when such a symptom would be
important to the scenario.
In addition to the need for high equipment
delity, simulation requires psychological
delity. This reects the degree to which
the trainee perceives the simulation to be a
believable representation of the reality it is
duplicating. Students may not take it seri-
ously, since mistakes or errors have no real
consequences on patient safety.
Along with equipment and psychological
delity, simulation requires environmental
delity that is, the realism of the environ-
ment in which the simulation takes place. For
example, emotional stress does not exist in
mannequins and standardized patients are
not really sick.
Cost. A study by McIntosh, et al. (2007)
calculated the set-up cost of a simulation
center was $876,485 (renovation of existing
facility, equipment). Fixed costs per year
totaled $361,425. Variable costs totaled $311
per course hour. The economic benets of
increasing the number of billable teaching
hours per week are signicant until about 21
hours (equivalent of three full or six and a
half day courses) per week (averaged over 52
weeks/year) when they started to taper off.
Lack of faculty time and training in simulation
instruction. Effective use of technology in
education depends on faculty readiness to
operate the tools for maximum educational
impact. It is important to recognize the need
for faculty training in the specic demands
which simulation-based teaching imposes.
Access to the simulator is limited and depen-
dent on the availability of instructors and
operators. Simulation also limits the number
of students that can be taught at any one
time.
Negative transfer. Negative transfer occurs if
the student learns something incorrectly due
to imperfect simulation. This most commonly
occurs because the instructor fails to make
National Council of State Boards of Nursing, Inc. (NCSBN) | 2009
3
BACKGROUND
clear to the students the differences between
the training device and the real situation.
These differences are usually due to a lack of
physical or equipment delity. For example,
the different feel of intubating a mannequin
or the articial acceleration of tasks might
imprint incorrect clinical practices or proce-
dures (Bond, et al., 2007).
Certain assessments are not possible, such
as reexes for example. Swelling and redness
does not appear, and the psychologic effects
of an illness and the emotional response of
the patient cannot be assessed using the
simulator (Lasater, 2007).
Review of the Literature
An examination of the literature related to simula-
tion reveals that despite a growing body of literature,
there is a substantial need for more evidence. Most
studies lack rigor, have small sample sizes, provide
little statistical analysis and conclusions are drawn
based on student perception.
Studies focusing on student reaction to the HPS
report positive responses to the simulation expe-
rience. In a review of the literature conducted by
Ravert (2002), 75% of the studies reviewed con-
cluded that students pursuing a degree in one of
the health professions favored or highly favored
simulation as a teaching/learning tool. In a qualita-
tive study by Mikkelson, Reime and Harris (2007),
students (N=21) who experienced the simulation-
based training stated they had greater awareness
of the complexity of a health care condition and
it raised their awareness to aspects they had not
thought of.
Two studies specically examined the impressions
of undergraduate nursing students. Bearnson and
Wilker (2005) used an HPS to demonstrate medi-
cation side effects to students. Students reacted
favorably to the experience and reported increased
knowledge of medication side effects and an under-
standing of the differences in patient responses;
it also increased their ability to safely administer
medications and their self-condence in medication
administration skills. No tests were administered to
establish whether the students perception actually
correlated with increased knowledge. No control
group was used to compare responses. Statistical
analysis beyond calculating the means of nominal
data collected from a questionnaire with Likert
scales was not performed. In addition, the report
does not describe the number of students that par-
ticipated in the study.
Lasater (2008) also examined high-delity simula-
tion experiences on nursing students (N=8) and
its effect on the development of clinical judgment.
Students enrolled in a Nursing Care of the Adult
course were given weekly simulation experiences
as part of the course. After the completion of the
course, eight of the 15 students participated in a
focus group and discussed their experience with
the HPS. Several themes emerged, including simu-
lation integrates learning; it increased the breadth
of experiences the students were exposed to; and
the scenarios forced them to anticipate potential
problems. The investigator concluded that this last
theme, anticipation of potential problems, was an
indication that simulation fostered clinical judg-
ment. While the experience may have done so, the
small sample size and the lack of outcome data
measuring performance makes it difcult to draw
a denite correlation between the HPS and clinical
judgment.
Several recent studies have attempted to determine
how simulation compares with traditional clinical
experience. The lack of consistency in the results,
however, makes drawing conclusions about simula-
tion difcult.
Alinar, Hunt, Gordon and Harwood (2006) com-
pared clinical performance of students in traditional
clinical settings with those that received clinical
experience (control) and clinical plus simulation
experience (experimental). Using a pretest/post-
test design, undergraduate nursing students (N=99)
were randomly assigned to one of these two groups.
Students were pre- and posttested using the
Objective Structured Clinical Examination (OSCE)
method. Students in both groups improved their
clinical performance; however, the experimental
group improved their performance on the OSCE 14
to 18 percentage points (95% CI 12.52-15.85) com-
pared to seven to 18 points (95% CI 5.33-9.05) in the
control group. The 7.0 percentage point difference
National Council of State Boards of Nursing, Inc. (NCSBN) | 2009
4
BACKGROUND
between the means (95% CI 4.5-9.5) was statistically
signicant (p< 0.001).
Radhakrishnan, Roche and Cunningham (2007)
conducted the rst study to test nursing student
performance with complex two-patient assign-
ment simulations. Undergraduate nursing students
(N=12) were randomized into a traditional clini-
cal experience (control) or a traditional clinical
experience plus simulation (intervention). Results
indicated that the intervention group had statisti-
cally signicant higher scores in two specic areas
of clinical performance: safety (p<= 0.001) and basic
assessment skills (p<= 0.009), when tested on a two-
patient simulator scenario. There were no signicant
differences in performance in any other clinical
parameters, which included focused assessment,
interventions, delegation and communication. This
study is limited by a small sample size, but may indi-
cate domains in which simulation offers strengths
over other methodologies in preparing students for
clinical practice.
Moule, WIlford, Sales and Lockyer (2008) report an
increase in knowledge and skills after simulation
training, but do not compare the effects with tra-
ditional clinical experience. This was a two-phase
study that examined knowledge acquisition through
pre- and posttests. Students (N=50) demonstrated
an increase in knowledge after the simulation expe-
rience through pre- and posttests, vignettes and
OSCE. The study also included a second phase,
which included interviews with six mentors of the
students who had undergone simulation training.
Through narrative reports, the study states that
the mentors felt students gained condence and
increased their learning from simulation, but no
statistical analysis was done on the data. Their rec-
ommendations include incorporating simulation as
part of the curriculum.
One of the most recent and largest studies to date
did not reveal differences between learning in a
hospital setting or simulation center. In a random-
ized controlled trial, Ellis, et al. (2008) studied the
effectiveness of simulation in the education of mid-
wives and obstetricians for eclampsia. Subjects (N=
132) were randomized into 24 different teams, which
were in turn randomized to a training program at a
local hospital or simulation center. Knowledge was
measured with pre- and postmultiple choice tests.
Posttraining exams revealed a 32% increase in mean
multiple choice score after the training, which was
statistically signicant (p<.001). There were, how-
ever, no differences in scores between the groups
that had the simulation training and those that did
not. Outcomes were also measured by videotap-
ing a standardized eclampsia scenario and grading
performance pre- and posttraining. Posttraining
videos revealed a statistically signicant increase in
the completion of tasks with greater speed (p=.012).
Improvements, however, were attributed to team-
work training. Simulation training did not elicit
additional improvement.
Variables
Three important variables have been selected to
be the focus of this study: knowledge, clinical per-
formance and condence. Nursing knowledge and
clinical performance are the basis for undergraduate
education and determine the level of competence
with which the new graduate enters the workforce.
Because of their importance, they will be observed
and measured in this study.
Condence has been shown to be an important
variable for undergraduate students. Students
who have increased self-condence have a better
chance at succeeding in their clinical goals (Lund-
berg, 2008) and are more likely to test and use their
clinical skills (Clark, Owen and Thoicken, 2004).
According to Albert Banduras classic theory on
self-efcacy, individuals with a strong sense of self-
efcacy or condence take on more challenges and
recover more quickly from failure. This sense of
self-efcacy develops from mastery experience
(Bandura, 1977). Thus, repetitive practice should
improve self-condence.
National Council of State Boards of Nursing, Inc. (NCSBN) | 2009
5
STUDY GOALS
STUDY GOALS
Specic goals of the study were to:
Examine the differences between tradi-
tional clinical experience and simulation as
teaching methods in prelicensure nursing
education;
Analyze how simulation training may impact
knowledge, clinical performance and con-
dence levels of undergraduate students and
compare this with traditional clinical experi-
ence; and
Contribute to the body of knowledge on
the uses and limitations of simulation in
prelicensure nursing education for both
regulators and educators.
These aims were accomplished by examining the
following:
Differences in pre- and postmultiple choice
exam scores in three groups of undergradu-
ate nursing students (clinical/simulation/
clinical plus simulation);
Differences in clinical performance between
three groups of undergraduate nursing
students (clinical/simulation/clinical plus
simulation); and
Differences in condence levels among three
groups of undergraduate students (clinical/
simulation/clinical plus simulation).
Despite the fact that simulation is widely accepted
as an educational tool, little research has examined
the role of simulation in prelicensure nursing educa-
tion in relation to clinical experiences. Moreover, it
is unknown to what degree high-delity simulation
would be an appropriate and suitable substitute
for real clinical experiences required by regulatory
rules for these nursing programs. As the rst step to
address this question, it is important to determine if
high-delity simulation provides an effective learn-
ing strategy.
National Council of State Boards of Nursing, Inc. (NCSBN) | 2009
6
RESEARCH QUESTIONS
RESEARCH QUESTIONS
1. Are there differences in knowledge between
prelicensure nursing students exposed to
a traditional intensive care unit (ICU) clini-
cal experience, those that have had only a
simulation experience and those that have
had a combination of clinical and simulation
experiences?
2. Are there differences in clinical performance
between prelicensure nursing students
exposed to a traditional ICU clinical experience,
those that have had only a simulation experi-
ence and those that have had a combination of
clinical and simulation experiences?
3. Are there differences in the levels of con-
dence between prelicensure nursing students
exposed to a traditional ICU clinical experience,
those that have had only a simulation experi-
ence and those that have had a combination of
clinical and simulation experiences?
National Council of State Boards of Nursing, Inc. (NCSBN) | 2009
7
METHODS
METHODS
Design and Sampling
The goal of this study was to compare the effec-
tiveness of simulation to actual clinical experience
among students enrolled in a prelicensure nursing
curriculum. The specic objective was to examine
the effectiveness and applicability of high-delity
simulation alone and in combination with clinical
experience on knowledge acquisition/retention,
self-condence and clinical performance of nursing
students.
A randomized controlled design with repeated
measures of pre- and posttreatment design was
used to address the aim of this study. The study was
reviewed and approved by the Institutional Review
Board of NCSBN and that of Rush University Medi-
cal Center.
All students in two separate cohorts (2006 and 2007)
of senior baccalaureate nursing students (n=92)
enrolled in a required critical care nursing course
at Rush University College of Nursing were asked
to participate. A total of 58 (cohort 1=23; cohort
2=25) chose to participate in the study. Students
who chose not to participate were assigned to the
usual treatment group, which for the course was the
simulation experience alone. After giving informed
consent and following the successful completion of
the three credit hour didactic portion of the course,
simple random selection was used to determine
group composition to one of the three practicum
experiences:
1. Clinical without simulation (30 hours of clini-
cal preceptorship with a critical care nurse);
2. Simulation without actual clinical experi-
ences (30 hours of simulation); or
3. Simulation plus clinical experience (15 hours
of simulation and 15 hours of clinical without
simulation).
Measurements of knowledge acquisition and
retention, and self-condence were taken before
beginning the didactic portion of the course and
after clinical or simulation experiences, while assess-
ment of clinical performance was taken after clinical
or simulation experiences (Figure 1).
Setting
The study was conducted at Rush University Col-
lege of Nursing because it not only had full access
to a state-of-the-art simulation laboratory, but also
offered an undergraduate course in critical care
nursing, which was deemed appropriate given the
type of experiences that could be offered in the
simulation laboratory. RUSL is a state-of-the-art
simulation training center equipped with life-sized,
computer-controlled virtual patients capable of sim-
ulating nearly any acute and critical patient episode,
including allergic reactions, drug overdoses, respi-
ratory distress, cardiac decompensation and acute
neurological events. Audio and video systems in the
adjoining classroom enables trainees and faculty to
observe teaching sessions, interact with the instruc-
tor and participate in guided performance feedback
sessions of the videotaped training session. Quali-
ed faculty with graduate preparation and expertise
in acute care clinical practice and simulation instruc-
tion implemented the study protocol.
Procedure
The course utilized for this project was modied
from an existing required course that consisted of
three credit hours of didactic instruction with no
planned simulation or clinical experiences. The new
course reected a 40-hour (didactic) undergradu-
ate critical care course with a 30-hour simulation
experience. All didactic content in the course was
front-loaded followed by simulation and/or clinical
experiences. Didactic teaching was provided to all
students in the form of lectures, required readings
and case studies.
The course occurred in the summer quarters after
the students successfully completed courses in
foundations of nursing, gerontological nursing,
basic medical-surgical nursing and psychiatric-
mental health nursing, which provided all students
with 270 hours of previous clinical experience. The
critical care course closely followed the American
Association of Critical Care Nursing core curricu-
lum, providing didactic content on all areas relative
to critical care nursing practice.
National Council of State Boards of Nursing, Inc. (NCSBN) | 2009
8
METHODS
The following simulation and/or clinical experiences
were offered:
Simulation only
Students in this group were exposed to a variety
of critical care nursing scenarios that emphasized
assessment and fundamental intervention. Students
spent approximately 30 hours in the simulator work-
ing on the following scenarios:
A patient with a myocardial infarction (MI)
and cardiogenic shock; includes experiences
in cardiovascular assessment, homodynamic
monitoring and EKG interpretation and
arrhythmia interventions;
A patient with acute respiratory distress;
includes experiences in respiratory assess-
ment, oxygen therapy and intubation/
mechanical ventilation; and
A patient with increased intracranial pressure
(ICP), includes experiences in neurological
assessment, basic intervention for changes in
level of consciousness (LOC) and ICP moni-
toring and interpretation.
Simulation and clinical
Students in this group spent 15 hours in the simula-
tor working on the scenarios described above and
then 15 hours (three ve-hour sessions) in a critical
care clinical experience providing direct, super-
vised care to a variety of critically-ill individuals.
Every attempt was made to provide students with
experiences in assessment of the cardiovascular,
respiratory and neurological systems; hemodynam-
ic and arrhythmia monitoring and interventions; and
oxygenation and mechanical ventilation.
Clinical only
Students spent 30 hours in a critical care unit
providing direct, supervised care to a variety of
critically-ill individuals. Every attempt was made to
provide students with experiences in assessment
of the cardiovascular, respiratory and neurological
systems; hemodynamic and arrhythmia monitoring
and interventions; and oxygenation and mechanical
ventilation.
Each scenario ran for approximately ve to 15 min-
utes, during which time the students were able to
ask questions of the patient; perform assessments
including vital signs, rhythm strips, heart and lung
sounds, and pupil changes; and provide interven-
tions, including starting IVs and assisting with
suctioning, intubation, etc. The student perfor-
mance in each scenario was tape recorded for a
debrieng session that followed each scenario for
discussion of the case, including critical thinking,
group coordination and decision making. To imple-
ment the simulation scenarios, relevant factors that
facilitated effective simulation-based learning syn-
thesized by Issenberg, et al. in 2005 were adopted.
The factors included providing feedback; allowing
repetitive practice; offering scenarios that were with
a range of difculty levels and clinical variations;
using multiple learning strategies in a controlled
environment; dening outcomes or benchmarks
prior to implementing scenarios; and using simula-
tors with high-delity.
Outcome Measures
Knowledge Acquisition and Retention
Knowledge acquisition and retention was assessed
with written examinations before and after clinical
and/or simulation experience. The scores from the
examination after clinical and/or simulation experi-
ence were used as proxy measures for knowledge
acquisition and retention, using pretest scores as
control. The pre- and postintervention examina-
tions were equivalent in content and were slightly
modied from existing examinations for the course.
The Cronbach alphas (KR-20) ranged from 0.6 to 0.7,
indicating this test produced repeatable measures
for this sample. All examinations were graded on a
scale from 0 100%, with higher scores indicating
higher levels of knowledge. The written examina-
tions consisted of 50 items reecting the content
taught in the course.
Clinical Performance
Clinical performance was assessed based on the
students performance on providing care during
three patient care scenarios, which were portrayed
by standardized patients. The three patient care
National Council of State Boards of Nursing, Inc. (NCSBN) | 2009
9
METHODS
scenarios included: (1) New onset of chest pain; (2)
Sudden onset of shortness of breath; and (3) Acute
change in level of consciousness. Each of these
scenarios were developed to present the student
with a situation in which they must assess and begin
primary intervention. The scenarios were designed
to be approximately 15 to 20 minutes in length.
Scores for each scenario were generated from a
blueprint, which was developed by four nurses who
were experts in the care of critically-ill clients using
the nursing process as a guide. These blueprints
reected the following principles:
The student asks appropriate, focused
questions that provide relevant information
leading to problem identication;
The student performs appropriate physical
assessments to conrm the patients subjec-
tive data and obtain objective data;
The student initiates basic nursing interven-
tions appropriate to the patients condition;
and
The student evaluates the effectiveness of
these interventions.
Three labs, with one lab for each of the three stan-
dardized patient encounters, were set up to mimic
a patient care environment equipped with essential
supplies and resources. A patient chart with relevant
information on the patient was available at the door
of the lab. Before beginning the individual evalu-
ation session, each student was provided with a
standardized orientation in verbal and written form.
Training of standardized patients and faculty evalu-
ators have been reported elsewhere by the study
investigators (Bosek, et al., 2007). The evaluation
process lasted from the moment the student entered
the room to begin the encounter with the standard-
ized patient until stopped by the faculty evaluator.
The faculty evaluator could also act as a physician or
other health care provider, as appropriate. Once the
evaluation was completed, it could not be modied.
No guidance from faculty was provided during the
performance. Students were not aware of the man-
ner by which they were being scored. If a student
performed a particular technique incorrectly, he or
she was provided with constructive feedback after
all three standardized patient scenarios had been
completed. Performance of the three groups of stu-
dents was compared to determine if there was an
advantage of high-delity simulation-based learn-
ing over actual clinical experience or vice versa.
Faculty Review of Videotaped Student
Performance
The performance of each student was videotaped
for further analysis of professional behaviors, assess-
ment, accuracy of intervention and total time from
encounter to implementation of intervention. Two
study investigators (who were also faculty members)
evaluated all taped scenarios on participants based
on a 28, 29 or 30-item evaluation tool, depending
on the scenario (Appendix A, B, and C). The tools
consisted of four dimensions: (1) Patient-nurse rela-
tionship; (2) Symptom recognition; (3) Assessment;
and (4) Intervention. Each action was evaluated
as Inadequate, Somewhat inadequate, Not
attempted, Somewhat adequate, or Ade-
quate. The reliabilities (Cronbachs alphas) of the
tools were 0.723 for chest pain, 0.787 for shortness
of breath and 0.782 for loss of consciousness sce-
narios. In addition, the total time from initial contact
to the end of the interaction was measured using
the video recorder timer. Examinations routinely
undergo extensive psychometric evaluation and
reliabilities have ranged from 0.6 to 0.7 on these
examinations in the past.
Self-condence
A Likert-type self-condence scale (Hicks, 2006)
consisting of 12 items was created to measure this
variable (Appendix D). The response option of each
item ranges from 1 (strongly disagree) to 4 (strongly
agree), with higher scores indicating greater self-
condence. The Cronbachs alphas of the scale on
the current data were 0.93 for pretest and 0.96 for
posttest, which demonstrates high internal consis-
tency reliability. The items reected the following
four dimensions:
1. Accurately recognizing a change in condi-
tions of patients with common critical care
issues;
2. Performing basic physical assessments for
condition of patients with common critical
care issues;
National Council of State Boards of Nursing, Inc. (NCSBN) | 2009
10
METHODS
3. Identifying basic nursing interventions for
conditions of patients with common critical
care issues; and
4. Evaluating the effectiveness of interventions
for conditions of patients with common criti-
cal issues.
Protection of Human Research
Subjects
For the purpose of this study, the following proce-
dures were instituted to protect the human subjects:
1. The project coordinator informed prospec-
tive subjects in writing of the purposes of the
study, the nature of their involvement, and the
potential benets and risks if they chose to
participate. The subjects were also informed
that taking part in the research was entirely
voluntary and they may withdraw from the
study at any time without anyone objecting and
without penalty or loss of any benets to which
they were otherwise entitled. The subjects
were told that they may or may not personally
benet from taking part in the research, but
the knowledge obtained may lead to a better
understanding of the role of simulation in nurs-
ing education.
2. Once the potential subjects were fully informed
of their rights, written informed consent was
then obtained from individuals who agreed
to participate in the study by the project
coordinator.
3. To ensure condentiality, code numbers were
assigned to each subject. Only the code
number appeared on the questionnaires and
records. A master list of names, addresses and
code numbers were maintained separately from
the collected data, in the event that follow-up
was needed. This list was available only to
the investigators and was destroyed following
completion of the study. Condentiality was
also guaranteed in that data were reported as
group data only.
Data Analysis
Multivariate analyses of variance with repeated
measures were performed to examine differences
among groups in outcome measures before (i.e.,
didactic instruction) and after clinical and/or simu-
lation experience. The outcome variables included
scores of written examinations, self-condence and
the indicators of the clinical performance with stan-
dardized patient scenarios among the three groups.
The independent variables included time and group
factors. Potential confounding variables and inter-
actions between main factors were examined prior
to the analysis of the group differences. All values
were represented as mean; standard deviation and
mean differences were considered signicant for a
P value less than 0.05. Bonferroni corrections were
applied as appropriate.
National Council of State Boards of Nursing, Inc. (NCSBN) | 2009
11
RESULTS
RESULTS
Since two cohorts of students (2006 and 2007) were
enrolled in the study, as the rst step in the analysis,
the cohorts were examined to see if there were any
differences between the two groups. No statistical
differences were identied. Thus, in the subsequent
analysis, the two cohorts of students were com-
bined and analyzed as one group.
Demographics
Of the 58 students that participated in the study,
the majority were female (84.5%) and white (73.7%)
with an average age of 26.8 years. More than half of
the students (59%) already had a bachelors degree
in other elds and 30% had working experience
in heath care. Approximately one-third (30.2%) of
the students had some experience in health care,
such as working as a nursing assistant or technician
in a lab. Three of the students who were assigned
to the combo group had previous experience with
simulation. There were no statistically signicant
differences in these demographic variables among
the groups (Table 1). These variables had no signi-
cant confounding effects in the analyses of group
differences.
Knowledge Acquisition and Retention
Students received didactic instruction for two
weeks, after which they took a multiple choice exam
Table 1. Demographics of Participants*
Simulation
(n=19)
Clinical
(n=19)
Combo
(n=20)
Total
(N=58)
Age in years (Mean and SD) 25.7 (6.1) 26.8 (6.7) 28.0 (5.5) 26.84 (6.1)
Female 89.5% 79.0% 85.0% 84.5%
White 68.4% 73.4% 75.0% 73.7%
With previous degree in other elds 52.6% 47.1% 50.0% 59.0%
With previous work experience in health care 22.2% 43.8% 26.3% 30.2%
*No signicant differences were found among groups in age, gender, race, having previous degrees in other eld or
having previous working experience in health care.
Table 2. Written Exam Scores Before and After Simulation/Clinical Experiences
Simulation*
(n=19)
Clinical*
(n=19)
Combo*
(n=20)
Total*
(N=58)
Exam Scores Mean SD Mean SD Mean SD Mean SD
Pre- 94.0 4.7 94.7 2.7 94.2 4.3 94.3 4.0
Post- 77.9 10.1 83.8 6.6 82.3 9.9 81.3 9.3
*All Ps<0.05; No group difference in both pretest and posttest were found.
to test their knowledge of the material covered. Stu-
dents then completed a two week practicum, after
which their clinical performance was assessed using
patient actors. After their encounters with the stan-
dardized patients, students again took a multiple
choice exam to assess their knowledge retention.
Based on written examinations on the content
taught in the critical care course, students in all
groups had statistically signicant lower scores on
the postexaminations (p<.000) after a two week peri-
od of practicum (Table 2). At the end of simulation
and/or clinical experiences, the students retained,
on average, 86.3% of the knowledge gained in the
didactic portion of the course. The simulation group
appeared to retain the least (82.9%) and the clini-
cal group the most (88.5%). However, no signicant
multivariate differences in change of knowledge
were found between the groups.
Clinical Performance Assessed with Standardized
Patients
For purposes of analysis, dichotomous variables
were created to indicate the adequateness of the
students performance. The inadequate, somewhat
adequate and not attempted responses were com-
bined into one group, and the somewhat adequate
or adequate responses into another group.
As indicated in Table 3, approximately one-third
National Council of State Boards of Nursing, Inc. (NCSBN) | 2009
12
RESULTS
Table 3. Clinical Performance on Three Patient Care Scenarios Portrayed by Standardized Patients: Tape Review Checklist Rating
1
Clinical Simulation Combo Probability
Inadequate,
Somewhat
Inadequate or
Not Attempted
Somewhat
Adequate or
Adequate
Inadequate,
Somewhat
Inadequate or
Not Attempted
Somewhat
Adequate or
Adequate
Inadequate,
Somewhat
Inadequate or
Not Attempted
Somewhat
Adequate or
Adequate
Chest pain symptoms 57% 43% 61% 39% 50% 50% 0.0001
Chest pain assessment 38% 63% 42% 58% 38% 63% 0.0139
Chest pain intervention 27% 73% 26% 74% 22% 78% 0.5496
Chest pain relationship 28% 72% 33% 62% 24% 76% 0.3237
Overall chest pain 36% 64% 39% 61% 33% 67% 0.1063
Shortness of breath
symptoms
32% 68% 45% 50% 39% 61% 0.1952
Shortness of breath
assessment
38% 62% 44% 53% 35% 65% 0.0358
Shortness of breath
intervention
23% 77% 39% 57% 35% 65% 0.0047
Shortness of breath
relationship
24% 76% 28% 66% 19% 81% 0.2063
Overall shortness of
breath
31% 69% 42% 58% 33% 67% 0.0002
Loss of consciousness
symptoms
25% 75% 24% 76% 26% 74% 0.9339
Loss of consciousness
assessment
39% 61% 43% 57% 38% 62% 0.6361
Loss of consciousness
intervention
30% 70% 40% 60% 29% 71% 0.0777
Loss of consciousness
relationship
3% 97% 5% 95% 5% 95% 0.7206
Overall loss of
consciousness
29% 71% 33% 66% 28% 71% 0.1686
Overall 32% 68% 34% 66% 32% 68% 0.1485
1
This table was constructed by counting the number of people who were rated as inadequate, somewhat adequate, not attempted, somewhat adequate or adequate
for each of the criterion in the three scenarios. The frequencies for each criterion were then summed to form four dimensions: patient-nurse relationship; symptom
recognition; assessment; and intervention. The ve categories of adequateness were then collapsed into two categories. The totals for each of the dimensions were then
converted into percentages. The percentages for each of the dimensions, therefore, do not represent the percent of students in each group (clinical, simulation, combo);
rather, it represents how often students were rated in a particular category.

For example, there are four criteria used to assess symptom recognition in the chest pain scenario. The number of students who were rated in each category is presented
below. Adding the results for the four criterion resulted in the 19 students in the simulation group being rated unsatisfactory 46 times and satisfactory 30 times. This
converts to percentages of 61% and 39%, respectively.
Footnote Table A
Symptom Recognition Criteria
Inadequate
Somewhat
Inadequate
Not
Attempted
Somewhat
Adequate
Adequate Total
Age in years (Mean and SD) 19 19
Female 13 3 3 19
White 2 15 2 19
With previous degree in other elds 1 15 1 2 19
With previous work experience in
health care
3 43 6 24 76
Footnote Table B
Symptom
Recognition
Inadequate, Somewhat
Inadequate or Not Attempted
Somewhat Adequate
or Adequate
Frequency 46 30
Footnote Table C
Symptom
Recognition
Inadequate, Somewhat
Inadequate or Not Attempted
Somewhat Adequate
or Adequate
Percentage 61% 39%
National Council of State Boards of Nursing, Inc. (NCSBN) | 2009
13
RESULTS
Table 4. Total Time to Complete Three Patient Care Scenarios Portrayed by Standardized Patients*
Simulation Clinical Combo All (n=57)
Total time to complete chest pain scenario in minutes 8.75 9.38 9.10 9.07
Total time to complete shortness of breath scenario in minutes 8.97 8.76 8.91 8.88
Total time to complete loss of consciousness scenario in minutes 8.60 10.08 10.28 9.64
*No group differences were found in the time needed to complete the scenarios between groups.
of the time the students in each group were rated
by faculty as not performing at satisfactory levels
across all scenarios. Students performed best on
level of consciousness relationship items and worst
on recognizing chest pain symptoms.
There were some statistically signicant differ-
ences between the groups of students at the 95%
condence level. The areas of differences included
recognizing chest pain symptoms, chest pain assess-
ment, assessing shortness of breath, shortness of
breath intervention and the overall shortness of
breath items.
While the overall differences between the three
groups were not statistically signicant, students
in the combo and clinical groups were consistently
rated higher by faculty reviewing the videotapes
than students in the simulation group.
Regarding the time needed to complete the scenar-
ios, the students took an average of 9.07 minutes to
complete the chest pain scenario; 8.88 minutes for
the shortness of breath scenario; and 9.64 minutes
for the loss of consciousness scenario. Although the
simulation group used a shorter period of time to
complete two out of the three scenarios, the differ-
ences were not statistically signicant (Table 4).
Self-condence
After receiving theoretical instruction of the critical
care content in the course, on average, students felt
somewhat condent in taking care of critically-ill
patients (average self-condence =3.53 on a scale
of 1-4). No signicant differences in self-condence
were found at pretest among all groups. At pretest,
the students were more condent in recognizing
symptoms (mean=3.55), conducting assessment
(mean=3.70) and evaluation (mean=3.55) than pro-
viding intervention (mean=3.30) (all Ps<0.05) (Table
6). This pattern held true for all groups (Table 5). The
differences in self-condence among the different
dimensions found at pretest disappeared at post-
test after the practicum experiences.
Students in the simulation and the combo groups
had a statistically signicant increase in their self-
condence level in taking care of patients with
acute changes in condition after clinical/simula-
tion experiences (Ps<0.05) (Table 6). No signicant
change in self-condence level was found for those
in the clinical group.
Course Evaluation
Undergraduate nursing students were asked to
evaluate the three credit-hour didactic/simulation
critical care nursing course. Students in the clini-
cal and the combination groups rated their clinical
experience with a 23-item questionnaire using
a scale of strongly disagree, disagree, agree or
strongly agree. For the most part, students either
agreed or strongly agreed with the statements
provided, indicating an overall positive experience
in the course. About one-quarter (23.5%) of the
students in the clinical group did not think clinical
faculty challenged their critical-thinking or problem-
solving skills. Almost one-fth (18.8%) of the same
group did not think clinical faculty were receptive
to views that differed from their own and 11.8% did
not think clinical expectations were applied equally
to all students. Almost one-third (29.5%) of the clini-
cal students either disagreed or strongly disagreed
with the statement that the clinical rotation pro-
vided them with a variety of learning experiences.
There were no statistically signicant differences in
how the clinical alone and the combination groups
rated their clinical experience (Table 7).
All students in the simulation and the combo groups
were asked about their simulation experience in the
course with a 14-item questionnaire using a scale of
strongly disagree, disagree, agree or strongly agree.
All of the students either agreed or strongly agreed
National Council of State Boards of Nursing, Inc. (NCSBN) | 2009
14
RESULTS
that the simulation experience provided them with
opportunities to improve learning, the feedback
received from the instructor during the simulation
was helpful to learning and the simulation scenarios
exposed them to cases with increasing levels of dif-
culty. About one-third of the students (29.5%) in
the simulation group felt that the simulator did not
have a high level of realism. There were no statisti-
cally signicant differences in simulation experience
between the simulation and the combo groups
(Table 8).
All students evaluated the effect of the clinical/sim-
ulation experience on their learning with a 14-item
questionnaire using a scale of strongly disagree,
disagree, agree or strongly agree. The majority of
the students either agreed or strongly agreed that
the clinical/simulation experience had enhanced
their skills in many aspects of nursing practice,
including physical and psychosocial assessment,
problem solving and decisionmaking, understand-
ing the basis for intervention, and developing the
role within the profession. About one-fth (16.6%)
of those in the clinical only group did not feel the
course enhanced their skills in developing a plan of
action. The same percentage also did not feel the
course helped them collaborate with others.
Table 6. Perceived Condence Before and After
Simulation/Clinical Experiences
Simulation*
(n=19)
Clinical
(n=19)
Combo*
(n=20)
Mean Mean Mean
Pre- 3.65 3.39 3.52
Post- 3.99 3.54 3.88
Increase in condence 0.34 0.15 0.36
*All Ps<0.05
Table 5. Dimensions of Perceived Condence Before and After
Simulation/Clinical Experiences
Dimension
Simulation
(n=19)
Clinical
(n=19)
Combo
(n=20)
Total
(n=58)
Mean Mean Mean Mean
1. Symptom Recognition
Pre- 3.63 3.42 3.59 3.55
Post- 4.04 3.57 3.92 3.85
2. Assessment
Pre- 3.88 3.56 3.65 3.70
Post- 4.05 3.70 3.92 3.89
3. Intervention
Pre- 3.40 3.06 3.39 3.30
Post- 3.86 3.41 3.80 3.70
4. Evaluation
Pre- 3.68 3.50 3.44 3.55
Post- 4.02 3.48 3.87 3.80
Among those in the simulation group, 16.7% did
not feel the course enhanced their skills in working
with diverse populations or groups. And among
the combination group, 18.8% did not feel their
documentation skills were enhanced. There were
no signicant differences on other items found
between the groups (Table 9).
National Council of State Boards of Nursing, Inc. (NCSBN) | 2009
15
RESULTS
Table 7. Perceived Clinical Experience
Variables
Clinical Group Combo Group
Strongly
Disagree
Disagree Agree
Strongly
Agree
Strongly
Disagree
Disagree Agree
Strongly
Agree
Clinical expectations were clearly stated
and reasonable.
5.9% 47.0% 47.0% 55.0% 45.0%
Clinical expectations were consistent
with course objectives.
11.8% 52.9% 35.3% 45.0% 55.0%
Clinical expectations were applied
equally to all students.
5.9% 5.9% 35.3% 52.9% 50.0% 50.0%
Clinical faculty were available for
consultation and assistance.
11.8% 29.4% 58.8% 40.0% 60.0%
Clinical faculty interacted non-
judgmentally with students from a variety
of backgrounds.
5.9% 41.2% 52.9% 40.0% 60.0%
Clinical faculty were receptive to views
that differed from their own.
6.3% 12.5% 31.3% 50.0% 5.0% 45.0% 50.0%
Clinical faculty were knowledgeable
about clinical practice.
35.3% 64.7% 35.0% 65.0%
Clinical faculty provided an environment
conducive to learning.
41.2% 52.8% 30.0% 70.0%
Clinical faculty interacted in a respectful,
non-threatening manner.
47.1% 52.9% 40.0% 60.0%
Clinical faculty took advantage of new or
unexpected learning opportunities.
11.8% 35.3% 52.9% 45.0% 55.0%
Clinical faculty challenged me to test my
own critical-thinking and problem-solving
skills.
232.5% 29.4% 47.1% 30.0% 70.0%
Clinical faculty facilitated faculty or
student conferences that enhanced
learning.
42.9% 57.1% 44.4% 55.6%
Clinical staff or preceptors were
supportive to students.
41.2% 58.8% 35.0% 65.0%
Clinical staff or preceptors were
knowledgeable about clinical practice.
35.3% 64.7% 35.0% 65.0%
Clinical staff or preceptors interacted
non-judgmentally with students from a
variety of backgrounds.
42.9% 57.1% 44.4% 55.6%
Clinical staff or preceptors interacted in a
respectful, non-threatening manner.
42.9% 57.1% 22.2% 77.8%
Clinical written assignments were
meaningful to my learning.
40.0% 60.0% 46.2% 46.2%
I received sufcient and timely feedback
to know how I was doing.
8.3% 33.3% 58.3% 55.6% 44.4%
My clinical evaluation was accurate and
fair.
27.8% 72.8% 50.0% 50.0%
Clinical experiences were equitably
distributed amongst students.
11.8% 52.9% 35.30% 57.9% 36.8%
My clinical assignments were consistent
with my abilities.
6.3% 43.8% 50.0% 65.0% 35.0%
I had opportunity to collaborate with
other health care providers.
50.0% 50.0% 75.0% 25.0%
This clinical rotation provided me with a
variety of learning experiences.
11.8% 17.7% 17.7% 52.9% 5.0% 35.0% 60.0%
National Council of State Boards of Nursing, Inc. (NCSBN) | 2009
16
LIMITATIONS OF THE STUDY
LIMITATIONS OF THE STUDY
The present study has certain limitations that need
to be taken into account when considering the
study and its contributions. The instruments used
were created to t the purpose of this study. While
the reliabilities are acceptable and the face validi-
ties are strong, the construct validities have yet to
be established.
No inter-rater reliabilities were established. Inter-
rater reliability is the degree of agreement among
raters. It gives a score of how much homogeneity, or
consensus, there is in the ratings given by judges. It
Table 8. Perceived Simulation Experience (n=37)
Variables
Simulation Combo
Strongly
Disagree
Disagree Agree
Strongly
Agree
Strongly
Disagree
Disagree Agree
Strongly
Agree
The feedback I received from
the instructor during the learning
experience was helpful to my learning.
47.1% 52.9% 55.0% 45.0%
The simulation experience provided
me with opportunities to improve my
learning.
52.9% 47.1% 35.0% 65.0%
The simulation scenarios exposed me to
cases with increasing levels of difculty.
23.5% 76.5% 35.0% 65.0%
The simulator was able to adapt to
multiple learning strategies.
6.7% 40.0% 53.3% 6.7% 60.0% 33.3%
The simulation scenarios exposed me
to a variety of situations that I may
encounter in practice.
5.9% 35.3% 58.8% 50.0% 50.0%
The simulation experience provided
individualized learning.
11.8% 41.2% 47.1% 10.0% 50.0% 40.0%
The simulation experience provided a
standardized experience for my student
group.
41.2% 58.8% 5.0% 55.0% 40.0%
The learning outcomes were clearly
identied.
52.9% 47.1% 10.0% 60.0% 30.0%
The simulation experiences were
appropriate to my level of learning.
52.9% 47.1% 50.0% 50.0%
I had the opportunity to engage in
making nursing decisions across a wide
range of difculty levels.
52.9% 41.2% 40.0% 60.0%
I had opportunities to actively
participate in the scenarios.
5.9% 41.2% 52.9% 35.0% 65.0%
The simulation experience adapted to
my unique learning needs.
5.9% 47.1% 41.2% 5.3% 42.1% 52.6%
The simulation experience allowed for
complex clinical tasks to be broken
down into their component parts for
educational mastery.
11.8% 52.9% 47.1% 5.0% 50.0% 45.0%
The simulator had a high level of
realism.
11.8% 17.7% 41.2% 29.4% 5.0% 10.0% 55.0% 35.0%
is useful in rening the tools given to human judges,
e.g., by determining if a particular scale is appro-
priate for measuring a particular variable. If various
raters do not agree, either the scale is defective or
the raters need to be retrained.
While the study was designed as a randomized trial,
it was not double blind. Although the faculty evalu-
ators were not informed of the group membership
of the students, it is possible they might have recog-
nized students through informal interactions and/or
during the teaching-learning process. It would have
National Council of State Boards of Nursing, Inc. (NCSBN) | 2009
17
LIMITATIONS OF THE STUDY
Table 8. Perceived Simulation Experience (n=37)
Variables
Simulation Combo
Strongly
Disagree
Disagree Agree
Strongly
Agree
Strongly
Disagree
Disagree Agree
Strongly
Agree
The feedback I received from
the instructor during the learning
experience was helpful to my learning.
47.1% 52.9% 55.0% 45.0%
The simulation experience provided
me with opportunities to improve my
learning.
52.9% 47.1% 35.0% 65.0%
The simulation scenarios exposed me to
cases with increasing levels of difculty.
23.5% 76.5% 35.0% 65.0%
The simulator was able to adapt to
multiple learning strategies.
6.7% 40.0% 53.3% 6.7% 60.0% 33.3%
The simulation scenarios exposed me
to a variety of situations that I may
encounter in practice.
5.9% 35.3% 58.8% 50.0% 50.0%
The simulation experience provided
individualized learning.
11.8% 41.2% 47.1% 10.0% 50.0% 40.0%
The simulation experience provided a
standardized experience for my student
group.
41.2% 58.8% 5.0% 55.0% 40.0%
The learning outcomes were clearly
identied.
52.9% 47.1% 10.0% 60.0% 30.0%
The simulation experiences were
appropriate to my level of learning.
52.9% 47.1% 50.0% 50.0%
I had the opportunity to engage in
making nursing decisions across a wide
range of difculty levels.
52.9% 41.2% 40.0% 60.0%
I had opportunities to actively
participate in the scenarios.
5.9% 41.2% 52.9% 35.0% 65.0%
The simulation experience adapted to
my unique learning needs.
5.9% 47.1% 41.2% 5.3% 42.1% 52.6%
The simulation experience allowed for
complex clinical tasks to be broken
down into their component parts for
educational mastery.
11.8% 52.9% 47.1% 5.0% 50.0% 45.0%
The simulator had a high level of
realism.
11.8% 17.7% 41.2% 29.4% 5.0% 10.0% 55.0% 35.0%
T
a
b
l
e

9
.

S
t
u
d
e
n
t

L
e
a
r
n
i
n
g

B
a
s
e
d

o
n

S
e
l
f
-
E
v
a
l
u
a
t
i
o
n
C
l
i
n
i
c
a
l
S
i
m
u
l
a
t
i
o
n
C
o
m
b
o
A
s

a

r
e
s
u
l
t

o
f

t
h
i
s

e
x
p
e
r
i
e
n
c
e
:
S
t
r
o
n
g
l
y

D
i
s
a
g
r
e
e
D
i
s
a
g
r
e
e
A
g
r
e
e
S
t
r
o
n
g
l
y

A
g
r
e
e
S
t
r
o
n
g
l
y

D
i
s
a
g
r
e
e
D
i
s
a
g
r
e
e
A
g
r
e
e
S
t
r
o
n
g
l
y

A
g
r
e
e
S
t
r
o
n
g
l
y

D
i
s
a
g
r
e
e
D
i
s
a
g
r
e
e
A
g
r
e
e
S
t
r
o
n
g
l
y

A
g
r
e
e
I

e
n
h
a
n
c
e
d

m
y

s
k
i
l
l
s

i
n

p
h
y
s
i
c
a
l

a
s
s
e
s
s
m
e
n
t
.
1
0
0
.
0
%
9
.
1
%
9
.
1
%
8
1
.
8
%
1
0
0
.
0
%
I

e
n
h
a
n
c
e
d

m
y

s
k
i
l
l
s

i
n

p
s
y
c
h
o
s
o
c
i
a
l

a
s
s
e
s
s
m
e
n
t
.
7
.
7
%
1
5
.
4
%
7
6
.
9
%
3
5
.
7
%
6
4
.
3
%
3
5
.
7
%
6
4
.
3
%
I

e
n
h
a
n
c
e
d

m
y

s
k
i
l
l
s

i
n

d
i
a
g
n
o
s
i
n
g

p
r
o
b
l
e
m
s

o
r

n
e
e
d
s
.
*
4
6
.
2
%
5
3
.
8
%
1
0
0
.
0
%
9
.
1
%
9
0
.
9
%
I

e
n
h
a
n
c
e
d

m
y

s
k
i
l
l
s

i
n

p
r
o
b
l
e
m

s
o
l
v
i
n
g

a
n
d

d
e
c
i
s
i
o
n

m
a
k
i
n
g
.
8
.
3
%
8
.
3
%
1
6
.
7
%
7
5
.
0
%
1
0
0
.
0
%
1
0
0
.
0
%
I

e
n
h
a
n
c
e
d

m
y

s
k
i
l
l
s

i
n

d
e
v
e
l
o
p
i
n
g

a

p
l
a
n

o
f

a
c
t
i
o
n
.
7
.
7
%
2
5
.
0
%
5
8
.
3
%
1
0
0
.
0
%
1
5
.
4
%
8
4
.
6
%
I

e
n
h
a
n
c
e
d

m
y

s
k
i
l
l
s

i
n

i
d
e
n
t
i
f
y
i
n
g

a
n
d

e
v
a
l
u
a
t
i
n
g

o
u
t
c
o
m
e
s
.
7
.
7
%
3
0
.
8
%
6
1
.
5
%
8
.
3
%
9
1
.
7
%
7
.
1
%
9
2
.
9
%
I

e
n
h
a
n
c
e
d

m
y

s
k
i
l
l
s

i
n

a
p
p
l
y
i
n
g

p
s
y
c
h
o
s
o
c
i
a
l

i
n
t
e
r
v
e
n
t
i
o
n
s
.
7
.
1
%
2
3
.
1
%
6
9
.
2
%
3
3
.
3
%
6
6
.
7
%
4
0
.
0
%
6
0
.
0
%
I

e
n
h
a
n
c
e
d

m
y

s
k
i
l
l
s

i
n

t
e
a
c
h
i
n
g

p
a
t
i
e
n
t
s

o
r

g
r
o
u
p
s
.
7
.
1
%
3
5
.
7
%
5
0
.
0
%
7
.
7
%
3
8
.
5
%
5
3
.
9
%
6
.
7
%
4
0
.
0
%
5
3
.
3
%
I

e
n
h
a
n
c
e
d

m
y

s
k
i
l
l
s

i
n

d
o
c
u
m
e
n
t
i
n
g

i
n
f
o
r
m
a
t
i
o
n
.
7
.
1
%
2
8
.
6
%
6
4
.
3
%
2
6
.
7
%
7
3
.
3
%
1
8
.
8
%
3
7
.
5
%
4
3
.
8
%
I

e
n
h
a
n
c
e
d

m
y

s
k
i
l
l
s

i
n

u
n
d
e
r
s
t
a
n
d
i
n
g

t
h
e

b
a
s
i
s

f
o
r

i
n
t
e
r
v
e
n
t
i
o
n
s
.
7
.
7
%
9
2
.
3
%
7
.
7
%
9
2
.
3
%
9
.
1
%
9
0
.
9
%
I

e
n
h
a
n
c
e
d

m
y

s
k
i
l
l
s

i
n

w
o
r
k
i
n
g

w
i
t
h

d
i
v
e
r
s
e

p
o
p
u
l
a
t
i
o
n
s

o
r

g
r
o
u
p
s
.
7
.
7
%
2
3
.
1
%
6
9
.
2
%
1
6
.
7
%
3
3
.
3
%
5
0
.
0
%
1
4
.
3
%
8
5
.
7
%
I

e
n
h
a
n
c
e
d

m
y

s
k
i
l
l
s

i
n

c
o
l
l
a
b
o
r
a
t
i
n
g

w
i
t
h

o
t
h
e
r
s
.
8
.
3
%
8
.
3
%
8
.
3
%
7
5
.
0
%
8
.
3
%
1
0
0
.
0
%
8
.
3
%
9
1
.
7
%
I

e
n
h
a
n
c
e
d

m
y

s
k
i
l
l
s

i
n

d
e
l
e
g
a
t
i
n
g

n
u
r
s
i
n
g

c
a
r
e

t
o

o
t
h
e
r
s
.
7
.
7
%
7
.
7
%
5
3
.
9
%
3
0
.
8
%
1
6
.
7
%
7
5
.
0
%
6
.
7
%
5
3
.
3
%
4
0
.
0
%
I

e
n
h
a
n
c
e
d

m
y

s
k
i
l
l
s

i
n

d
e
v
e
l
o
p
i
n
g

m
y

r
o
l
e

w
i
t
h
i
n

t
h
e

p
r
o
f
e
s
s
i
o
n
.
8
.
3
%
1
6
.
7
%
7
5
.
0
%
1
0
0
.
0
%
8
.
3
%
9
1
.
7
%
*
p
=
0
.
0
2
National Council of State Boards of Nursing, Inc. (NCSBN) | 2009
18
LIMITATIONS OF THE STUDY
been ideal to have the evaluators completely blind
of the study design, however, due to the number of
faculty needed for the study, it was not feasible to
do so.
There was also considerable previous clinical expe-
rience among the students. All of the students had
270 hours of previous clinical experience before
taking the course. Three of the students also had
previous experience with a simulator. These previ-
ous experiences make if difcult to understand the
true effects of simulation and clinical experience on
clinical performance.
Another limitation of this study includes external
validity, or the generalizability of the study. There
were only 58 students who participated, dispersed
among three groups of 19, 20 and 19 students each.
An example of how the small sample size limits the
conclusions that can be drawn can be examined by
looking at differences between the groups in the
number of students who had a previous degree.
The simulation group had 5.5% more students with
previous degrees than the clinical group. It may be
that having a previous degree would increase a per-
sons condence, but 5.5% in this study represents
only one person out of the group. While in a larger
sample, a 5.5% difference in prior experience may
affect condence, in this study, it is unlikely that one
persons background would have much effect.
A question can also be raised as to whether the
study is actually measuring condence or more
generally measuring attitudes and other common
mechanisms toward clinical performance. The study
assesses condence globally, with a few scale items
that ask participants to report on their condence
or efcacy without regard to specic performance
tasks. At this level of self-reporting, it is expected
that condence can not reliably be separated from
other personal determinants, such as self-concept,
anxiety, self-condence and background.
National Council of State Boards of Nursing, Inc. (NCSBN) | 2009
19
DISCUSSION
DISCUSSION
As this study indicates, evaluating the impact of
simulation-based training on clinical performance
remains a signicant challenge. Given the limitations
of this study, the effects of simulation on nursing
students clinical performance remains inconclusive.
In terms of knowledge retention, students actually
decreased their knowledge as measured by a 50-
item test. However, differences between the three
groups of students were not statistically signicant.
The clinical performance demonstrated by simu-
lation-based assessment between the groups with
simulation-based learning, a combination of simula-
tion-based and bed-side actual clinical experience,
and bed-side actual clinical experience alone also
indicated no differences between the groups in
terms of overall means of the ratings. However,
students in the combo group tended to receive
the highest scores followed by those in the clinical
group. Replicating the study with larger samples
and across different settings would probably elu-
cidate whether or not such a tendency was due to
chance or not.
For beginning senior level nursing students in either
the simulation-based learning or a combination of
simulation-based and bed-side learning, actual
clinical experience showed a statistically signicant
increase in their self-condence of taking care of
critically-ill patients. However, the perceived abili-
ties and condence of participants are of no value if
higher level problem solving, decision making and
psychomotor skills are not evident through replica-
tion in clinical practice.
National Council of State Boards of Nursing, Inc. (NCSBN) | 2009
20
AVENUES OF FUTURE RESEARCH
AVENUES OF FUTURE RESEARCH
While the effects of simulation remain elusive, this
study lays the foundation for further research. The
ndings tease us with the notion that clinical expe-
rience in combination with simulation training may
provide the best performance outcomes. Addition-
al research with large cohorts of learners and the
knowledge gained from this study can provide bet-
ter evidence as to the benets of simulation-based
training.
National Council of State Boards of Nursing, Inc. (NCSBN) | 2009
21
REFERENCES
REFERENCES
Aliner, G., Hunt B., Gordon R. and Harwood C. (2006). Effectiveness of intermediate-delity simulation
training technology in undergraduate nursing education. J Adv Nurs, 54(3), 359-369.
Bandura, A. (1986). Social foundations of thought and action: A social cognitive. Englewood Cliffs,
NJ: Prentice Hall.
Bandura, A. (1977). Self-efcacy: Toward a unifying theory of behavioral change. Psychological Review,
84(2), 191-215.
Bearnson, C.S. and Wiker, K.M. (2005). Human patient simulators: A new face in baccalaureate nursing
education at Brigham Young University. J Nurs Educ, 44(9), 421-425.
Becker, K.L., Rose, L.E., Park, H. and Shatzer, J.H. (2006). The teaching effectiveness of standardized
patients. J Nurs Educ, 45(4),103-111.

Bond, W.F., et al. (2007). The use of simulation in emergency medicine: A research agenda. Acad Emerg
Med, 14(4), 353364.
Bosek, M.S., Li S. and Hicks F.D. (2007). Working with standardized patients: A primer. Int J Nurs Educ
Scholarsh, 4(16).
Boulet, J.R., Murray, D., Kras, J., Woodhouse, J., McAllister, J. and Ziv, A. (2003). Reliability and validity of
a simulation-based acute care skills assessment for medical students and residents.
Anesthesiology, 99(6),1270-1280.
Chopra, V., Gesink, B.J., DeJong, J., Spierdijk, J. and Brand, R. (1994). Does training on an anaesthesia
simulator lead to improvement in performance? Br J Anaesth, 73(3), 293-297.
Ciof, J., Purcal, N. and Arundell, F. (2005). A pilot study to investigate the effect of a simulation strategy
on the clinical decision making of midwifery students. J Nurs Educ, 44(3), 131-134.
Clark, M.C., Owen, S.V. and Tholcken, M.A. (2004). Measuring student perceptions of clinical competence.
J Nurse Educ, 42(12), 548-554.
Day, L. (2007). Simulation and the teaching and learning of practice in critical care units. Am J of Crit Care,
16(5), 504-507.
Decker, S., Sportsman, S., Puetz, L. and Billings, L. (2008). The evolution of simulation and its contribution
to competency. J Contin Educ Nurs, 39(2), 74-80.
Ellis, D., Crofts, J.F., Hunt, L.P., Read, M., Fox, R. and James, M. (2008). Hospital, simulation center, and
teamwork training for eclampsia management: A randomized controlled trial. Am J Obstet
Gynecol, 111(3), 723-731.
Gaba, D.M. (2000) Anaesthesiology as a model for patient safety in health care. BMJ, 320(7237), 785788.
National Council of State Boards of Nursing, Inc. (NCSBN) | 2009
22
REFERENCES
Gaba, D.M. (2004). The future vision of simulation in health care [Electronic version]. Qual Saf Health Care,
13(Suppl. 1), i2-i10.
Galbraith, M.W. (Ed). (2004). Adult Learning Methods: A guide for effective instruction (3rd ed.)
(pp. 261-281). Florida: Krieger.
Gomez, G.E., and Gomez, E.A. (1987). Learning of psychomotor skills: Laboratory versus patient care
setting. J Nurs Educ, 26(1), 20-24.
Gredler, M. (1992). Designing and evaluating games and simulations: A process approach. London, UK:
Kogan Page.
Hertel, J.P. and Millis, B.J. (2002). Using simulations to promote learning in higher education: An
introduction. Sterling, VA: Stylus.
Hicks, F.D. (2006). Clinical Decision-Making Self-Condence Scale.
Hogan, M.P., Pace, D.E., Hapgood, J. and Boone, D.C. (2006). Use of human patient simulation and the
situation awareness global assessment technique in practical trauma skills assessment. J Trauma,
61(5), 1047-1052.
Issenberg, S.B., McGaghie, W.C., Petrusa, E.R., Lee Gordon, D. and Scalese, R.J. (2005). Features and uses
of high-delity medical simulations that lead to effective learning: A BEME systematic review.
Med Teach, 27(1), 10-28.
Jarzemsky, P.A. and McGrath, J. (2008). Look before you leap: Lessons learned when introducing clinical
simulation. Nurs Educ, 33(2), 90-95.
Lane, C. and Rollnick, S. (2007). The use of simulated patients and role-play in communication skills
training: A review of the literature to August 2005. Patient Educ Couns, 67(1-2), 13-20.
Lasater, K. (2007). High-delity simulation and the development of clinical judgment: Students
experiences. Journal of Nursing Education, 46(6), 269-276.
Lauber, J. K. (1987). Cockpit resource management: Background studies and rationale. In H. W. Orlady &
H. C. Foushee (Eds.). Cockpit resource management training (Tech. Rep. No. NASA CP-2455).
Moffett Field, CA: NASA Ames Research Center.
Lederman, L.C. (1992). Debrieng: A critical reexamination of the post experience analytic process with
implications for its effective use. Simul Gaming, 23(2), 145-160.
Long, R.E. (2005). Using simulation to teach resuscitation: An important patient safety tool. Crit Care Nurs
Clin North Am, 17(1), 1-8, ix.
Lundberg, K.M. (2008). Promoting self-condence in clinical nursing students. Nurs Educ, 33(2), 86-89.
Maran, N.J. and Glavin, R.J. (2003). Low- to high-delity simulation A continuum of medical education?
Med Educ, 37(Suppl. 1), 2228.
National Council of State Boards of Nursing, Inc. (NCSBN) | 2009
23
REFERENCES
Mcintosh, C., Macario, A., Flanangan, B. and Gaba, D.M. (2005). Simulation: What does it really cost?
Poster session presented at the SimTecT 2005 Healthcare Simulation Conference, Brisbane,
Australia.
Mikkelsen, J., Reime, M.H. and Harris, A.K. (2007). Nursing students learning of managing
cross-infections Scenario-based simulation training versus study groups. Nurs Educ Today,
28(6), 664-671.
Moule, P., Wilford, A., Sales, R. and Lockyer, L. (2008). Student experiences and mentor views of the use of
simulation for learning. Nurs Educ Today, 28(7), 790-797.
Radhakrishnan, K., Roche, J.P. and Cunningham, H. (2007). Measuring clinical practice parameters with
human patient simulation: A pilot study. Int J Nurs Educ Scholarsh, 4(1).
Ravert, P. (2002). An integrative review of computer-based simulation in the education process. Comput
Inform Nurs, 20(5), 203-208.
Scalese, R.J. Obeso, V.T. and Issenberg, S.B. (2008). Simulation technology for skills training and
competency assessment in medical education. J Gen Intern Med, 23 (Suppl. 1), 46-49.
Shavit, I., Keidan, I., Hoffman, Y., Mishuk, L., Rubin, O., Ziv, A. and Steiner, I.P. (2007). Enhancing patient
safety during pediatric sedation. The impact of simulation-based training of
nonanesthesiologists. Arch Pediatr Adolesc Med, 161(8), 740-743.
Tuoriniemi, P. and Schott-Baer, D. (2008). Implementing a high-delity simulation program in a community
college setting. Nurs Educ Perspect, 29(2), 105-109.
Wilson, M., Shepherd, I., Kelly, C. and Pitzner, J. (2005). Assessment of a low-delity human patient
simulator for the acquisition of nursing skills. Nurs Educ Today, 25(1), 56-67.
Ziv, A., Wolpe, P.R., Small, S.D. and Glick, S. (2003). Simulation-based medical education: An ethical
imperative. Acad Med, 78(8), 783788.
National Council of State Boards of Nursing, Inc. (NCSBN) | 2009
24
APPENDIX A: CHEST PAIN SCENARIO
APPENDIX A: CHEST PAIN SCENARIO
Appendix A: Evaluation of Videotapes Chest Pain Scenario
Criteria Chest Pain Scenario Inadequate
Somewhat
Inadequate
Not
Attempted
Somewhat
Adequate Adequate
Patient-nurse relationship
1. Called the patient by his/her name. -2 -1 0 1 2
2. Informed him/her the purpose of the encounter. -2 -1 0 1 2
3. Demonstrated professional demeanor when approaching and
communicating with patient.
-2 -1 0 1 2
4. Was calm and reassuring. -2 -1 0 1 2
5. Demonstrated empathy and respect. -2 -1 0 1 2
Symptom Recognition
6. Acknowledged chest pain as abnormal nding. -2 -1 0 1 2
7. Acknowledged non-verbal patient reaction to pain by
verbalizing patients discomfort.
-2 -1 0 1 2
8. Acknowledged the patients anxiety and reassures the patient
appropriately.
-2 -1 0 1 2
9. Recognized patients history -2 -1 0 1 2
Assessment
10. Elicited when pain started. -2 -1 0 1 2
11. Elicited quality of the pain. -2 -1 0 1 2
12. Elicited what makes pain better or worse. -2 -1 0 1 2
13. Elicited if pain radiates. -2 -1 0 1 2
14. Elicited severity of pain. -2 -1 0 1 2
15. Elicited information about headache. -2 -1 0 1 2
16. Took BP. -2 -1 0 1 2
17. Took pulse. -2 -1 0 1 2
18. Took respiration. -2 -1 0 1 2
19. Palpated skin and notes skin color. -2 -1 0 1 2
20. Auscultated lung elds thoroughly. -2 -1 0 1 2
21. Reassessed chest pain after giving nitroglycerin. -2 -1 0 1 2
22. Reassessed vital signs after nitroglycerin. -2 -1 0 1 2
Interventions
23. Placed patient in high Fowlers position. -2 -1 0 1 2
24. Placed oxygen nasal cannula and turns on the ow meter
to 2l/min.
-2 -1 0 1 2
25. Explained ndings to the patient. -2 -1 0 1 2
26. Gave Nitroglycerin SL. -2 -1 0 1 2
27. Described all interventions and their rationale to the patient. -2 -1 0 1 2
28. Recognized need to report ndings to the physician. -2 -1 0 1 2
29. Provided adequate report of ndings when prompted
by instructor (i.e., physician report).
-2 -1 0 1 2
Participant Number:_______________________________________________ Total time to complete scenario: ________________
Scenario: _____________________________________________________________________________
Inappropriate/illogical actions: 1.___________ 2.___________ 3. ___________ 4.____________
Other appropriate actions: 1.___________ 2.___________ 3. ___________ 4.____________
National Council of State Boards of Nursing, Inc. (NCSBN) | 2009
25
APPENDIX B: SHORTNESS OF BREATH SCENARIO
APPENDIX B: SHORTNESS OF BREATH SCENARIO
Appendix B: Evaluation of Videotapes Shortness of Breath Scenario
Criteria Shortness of Breath Scenario Inadequate
Somewhat
Inadequate
Not
Attempted
Somewhat
Adequate Adequate
Patient-nurse relationship
1. Called the patient by his/her name. -2 -1 0 1 2
2. Informed him/her the purpose of the encounter. -2 -1 0 1 2
3. Demonstrated professional demeanor when approaching
and communicating with patient.
-2 -1 0 1 2
4. Was calm and reassuring. -2 -1 0 1 2
Symptom Recognition
5. Acknowledges shortness of breath (SOB) as an
abnormal nding.
-2 -1 0 1 2
6. Acknowledges non-verbal patient reaction to SOB. -2 -1 0 1 2
7. Acknowledges patients fear and reaction to pain. -2 -1 0 1 2
8. Recognizes patients history. -2 -1 0 1 2
Assessment
9. Assessed onset of SOB. -2 -1 0 1 2
10. Assessed character of SOB. -2 -1 0 1 2
11. Assessed intensity of SOB. -2 -1 0 1 2
12. Assessed contributory factors for SOB. -2 -1 0 1 2
13. Assessed associative factors for SOB. -2 -1 0 1 2
14. Took BP. -2 -1 0 1 2
15. Palpated radial pulse. -2 -1 0 1 2
16. Took respiration. -2 -1 0 1 2
17. Auscultated lung elds thoroughly. -2 -1 0 1 2
18. Inspected nail bed and lips for cyanosis. -2 -1 0 1 2
19. Determined level of assistance patient needs for returning
to bed.
-2 -1 0 1 2
20. Determined SpO2. -2 -1 0 1 2
21. Checked postoperative dressing. -2 -1 0 1 2
Interventions
22. Assisted patient back to bed. -2 -1 0 1 2
23. Placed patient in high Fowlers position. -2 -1 0 1 2
24. Placed oxygen nasal cannula. -2 -1 0 1 2
25. Instructed the patient on focused breathing. -2 -1 0 1 2
26. Described all interventions and their rationale to the patient. -2 -1 0 1 2
27. Recognized need to report ndings to the physician. -2 -1 0 1 2
28. Provided adequate report of ndings when prompted
by instructor (i.e., physician report).
-2 -1 0 1 2
29. Repeated physicians orders. -2 -1 0 1 2
Participant Number:_______________________________________________ Total time to complete scenario: ________________
Scenario: _____________________________________________________________________________
Inappropriate/illogical actions: 1.___________ 2.___________ 3. ___________ 4.____________
Other appropriate actions: 1.___________ 2.___________ 3. ___________ 4.____________
National Council of State Boards of Nursing, Inc. (NCSBN) | 2009
26
APPENDIX C: LEVEL OF CONSCIOUSNESS SCENARIO
Appendix C: Evaluation of Videotapes Level of Consciousness Scenario
Criteria Change in Level of Consciousness Scenario Inadequate
Somewhat
Inadequate
Not
Attempted
Somewhat
Adequate Adequate
Patient-nurse relationship
1. Called the patient by his/her name. -2 -1 0 1 2
2. Informed him/her the purpose of the encounter. -2 -1 0 1 2
3. Demonstrated professional demeanor when approaching and
communicating with patient.
-2 -1 0 1 2
4. Was calm and reassuring. -2 -1 0 1 2
5. Demonstrated empathy and respect.
Symptom Recognition
6. Acknowledged change in level of consciousness (LOC) as an
abnormal nding.
-2 -1 0 1 2
7. Determined level of arousal. -2 -1 0 1 2
8. Acknowledged confusion/disorientation. -2 -1 0 1 2
9. Acknowledged patients history as contributing factor. -2 -1 0 1 2
Assessment
10. Assessed orientation three times. -2 -1 0 1 2
11. Took blood pressure. -2 -1 0 1 2
12. Took pulse. -2 -1 0 1 2
13. Took respiration. -2 -1 0 1 2
14. Checked pupil reaction. -2 -1 0 1 2
15. Assessed upper extremity (UE) strength. -2 -1 0 1 2
16. Assessed lower extremity (LE) strength. -2 -1 0 1 2
17. Assessed upper extremity (UE) sensation. -2 -1 0 1 2
18. Assessed lower extremity (LE) sensation. -2 -1 0 1 2
19. Inspected face for symmetry. -2 -1 0 1 2
Interventions
20. Placed patient on back. -2 -1 0 1 2
21. Raised head of bed angle (HOB) to 45 degrees. -2 -1 0 1 2
22. Placed oxygen nasal cannula. -2 -1 0 1 2
23. Described all interventions and their rationale to the patient. -2 -1 0 1 2
24. Recognized need to report ndings to physician. -2 -1 0 1 2
25. Provided adequate report of ndings when prompted by
instructor (i.e., physician report).
-2 -1 0 1 2
26. Repeated physician orders. -2 -1 0 1 2
27. Side rails up. -2 -1 0 1 2
28. Reoriented patient to person, place, and time (PPT). -2 -1 0 1 2
Participant Number:_______________________________________________ Total time to complete scenario: ________________
Scenario: _____________________________________________________________________________
Inappropriate/illogical actions: 1.___________ 2.___________ 3. ___________ 4.____________
Other appropriate actions: 1.___________ 2.___________ 3. ___________ 4.____________
APPENDIX C: LEVEL OF CONSCIOUSNESS SCENARIO
National Council of State Boards of Nursing, Inc. (NCSBN) | 2009
27
APPENDIX D: SELF-CONFIDENCE SCALE
Appendix D: Self-condence Scale
Not at all
condent
Somewhat
not condent
Somewhat
condent
Moderately
condent
Very
condent
1. How condent are you that you can recognize signs and
symptoms of a cardiac event?
1 2 3 4 5
2. How condent are you that you can recognize signs and
symptoms of a respiratory event?
1 2 3 4 5
3. How condent are you that you can recognize signs and
symptoms of a neurological event?
1 2 3 4 5
4. How condent are you that you can accurately assess an
individual with chest pain?
1 2 3 4 5
5. How condent are you that you can accurately assess an
individual with shortness of breath?
1 2 3 4 5
6. How condent are you that you can accurately assess an
individual with changes in mental status?
1 2 3 4 5
7. How condent are you that you can appropriately intervene for
an individual with chest pain?
1 2 3 4 5
8. How condent are you that you can appropriately intervene for
an individual with shortness of breath?
1 2 3 4 5
9. How condent are you that you can appropriately intervene for
an individual with changes in mental status?
1 2 3 4 5
10. How condent are you that you can evaluate the effectiveness
of your interventions for an individual with chest pain?
1 2 3 4 5
11. How condent are you that you can evaluate the effectiveness
of your interventions for an individual with shortness of breath?
1 2 3 4 5
12. How condent are you that you can evaluate the
effectiveness of your interventions for an individual with
changes in mental status?
1 2 3 4 5
APPENDIX D: SELF-CONFIDENCE SCALE
111 E. Wacker Drive, Suite 2900
Chicago, IL 60601-4277
312.525.3600
312.279.1032 fax
www.ncsbn.org 978-0-9822456-5-1