Simulating Fidelity In Nursing Education Essay

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For years nurses have gained experience in the medical field through clinical rounds at hospitals and doctors offices. Learning has always taken place first through textbooks and then through personal experience during required clinical time. These methods have proven effective but include limitations to the amount of exposure a student can gain before entering the workforce. A new way of learning is on the rise with the use of High Fidelity Simulations (HFS) or the Sim Man. HFS is a computerized life size manikin that simulates real human responses to treatment. This new technology allows students to practice rare procedures or treat common diagnoses. Although these…show more content…
These skills may be compromised if majority of the student’s training is focused on the Sim Man. In a experiment done comparing the test results from students using traditional teaching methods and HFS, twelve different studies showed no dramatic increase or decrease in a students testing ability after training from both styles. (Robyn and Simon 2010) However, students noted that HSF training allowed them to implement their prior textbook knowledge in practical procedures. The positive approach to HFS training allows patients lives to not be put at risk during the teaching process. Student’s can practice administering a catheter or assisting in surgery without the added stress of harming the patient.Simulating Fidelity In Nursing Education Essay  HFS allows students to practice complicated procedures they otherwise may not have the opportunity to participate in. From poison to natural disaster, with HFS students can practice group situations and emergency preparedness and have time to reflect on what they could do better next time. (Garrett, B., Macphee, M., Jackson, C. 2010) Cost vs. Effectiveness of HFS training Like many other technological advances, HFS is a very expensive training tool. A cost analysis done showed the cost per resident for HFS setup was around $260 for the first year and $203 for the additional years opposed to less than $5 for lecture setup (Petscavage JM, Wang CL, Schopp JG, Paladin AM, Richardson ML, Bush WH Jr. Acad Radiol 2011).
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The explosion in the use of simulation has occurred because of
Aspect 1: Factors That Have Led to an Increase in Simulation in Nursing Education Simulating Fidelity In Nursing Education Essay
Appraising factors leading to an increase in the use of simulation for nursing education allows for understanding how to further develop the pedagogy used with simulation. Analyzing what has influenced its rise in use allows for insight and planning for future technology developments. Most of today’s nurses can recall only using low-fidelity mannequins in learning about basic nursing care.
One of the most influential factors in utilizing high-fidelity simulation mannequins has been computer and technology development. Computer programming, memory, graphics, internet and robotics developed a pathway to allow for its incorporation into training this generation of nurses. The cost-point of materials and production dropped to an expensive, but reasonable, acquisition of technology for the educational setting.
Increased use of high-fidelity resources led to further incorporation and study of outcomes associated with its use. Educators have found that using simulation benefits students with superior learning opportunities through exposure to high-risk scenarios not always accomplished in live clinical settings, an environment to explore patient care errors without causing actual patient harm, and an opportunity for direct observation of student actions and reflection on thinking process (Adamson, 2015). As a proven Simulating Fidelity In Nursing Education Essay

A New Way of Learning: High Fidelity Simulation in Nursing Education

For years nurses have gained experience in the medical field through clinical rounds at hospitals and doctors offices. Learning has always taken place first through textbooks and then through personal experience during required clinical time. These methods have proven effective but include limitations to the amount of exposure a student can gain before entering the workforce. A new way of learning is on the rise with the use of High Fidelity Simulations (HFS) or the Sim Man. HFS is a computerized life size manikin that simulates real human responses to treatment. This new technology allows students to practice rare procedures or treat common diagnoses.Simulating Fidelity In Nursing Education Essay
Although these changes bring about concerns with the traditional nursing community, technological advances have pushed the medical field far beyond the ideas of early traditional medicine. From high resolution CAT scans to computer check in systems nursing continues to change. These advances have incorporated into the way nursing education is taught. The Sim Man allows for students to witness and participate in the possible outcomes of the correct and incorrect ways of treating different diagnoses. This style of training also includes High Fidelity Simulation situations where actors play the roles of Doctors or Anesthetists allowing students the practice with other people in the medical field. This teaching technique is fairly new and controversial.
Traditional Training vs. High Fidelity Simulations
Traditional training incorporates one on one contact with live patients. Students not only gain experience in the field of medicine but they learn how to communicate with all differ Simulating Fidelity In Nursing Education Essay

The role of high-fidelity clinical
simulation in teaching and learning in
the health professions
Claire Bradley
School of Medicine, King’s College London
Submitted April 2011
This essay reviews some of the literature about development of expert practice in medicine and related
health professions. It uses adult education theory, Vygotsky’s notion of learning in the ‘zone of proximal
development’ and some of the more general higher education literature in order to produce a critical
analysis of the benefits of high fidelity simulation experiences. Conclusions point towards the validity
of constructivist educational theories and their specific relevance in a medical educational context. The
work constitutes critical advocacy for use of simulation training methods in Nursing and Allied Health
Professions with the argument resting on the ways that these professional identities are constituted in the
interplay of theoretical knowledge and practice application.
Introduction Simulating Fidelity In Nursing Education Essay
Traditionally pre-registration medicine and healthcare education involves the acquisition and learning
of classroom-based facts and theories interspersed with discrete periods of clinical practice which
supposedly serve to consolidate students’ knowledge and prepare them for work once qualified. Due to
the legal requirements for supervision, patient safety and the increasing frequency of litigation against the
healthcare sector there is often limited opportunity for students to meaningfully explore and develop their
newly acquired knowledge in the clinical setting which often involves dealing with unexpected situations
and medical emergencies (Murray, 2006). It is my experience as both a teacher in higher education and
a clinical practice educator that the link between theory and practice is not always easily elicited by
students: classroom-based teaching often involves information transmitted to students as discrete topics
in lectures or seminars which often fail to highlight the interrelation of one topic to another. This makes
clinical reasoning and the management of ‘real life’ patients difficult as the relationships between these
discrete facts is not always immediately obvious to the student in the clinical situation. In addition to
this difficulty in transferring and transforming knowledge, students studying for a degree in medicine or
healthcare-related professions are often rewarded in assessment for the memorisation and regurgitation of
theories and knowledge through essays, multiple choice questions (MCQ’s) or in a six minute objective
structured clinical exam (OSCE). These current assessment methods reward rote learning (Gibbs and
Simpson, 2005), placing little emphasis for students on safe and effective patient management, teamwork
and reflective practice, all of which are considered core attributes and skills of the modern healthcare
professional. This poses the question; do current UK undergraduate training and assessment methods meet
the needs of the health professional once qualified? This paper aims to explore the role of high-fidelity
clinical simulation as an approach to overcoming some of these challenges and problems, potentially
enhancing the teaching and learning strategies currently used in the education of medics, nurses and allied
health professionals (AHP’s).
High-fidelity Clinical Simulation
It has previously been proven that technical faults are to blame for only 30 per cent of all clinical
complications; the remaining 70 per cent are due to mistakes made by health professionals (Paver-Erzen
and Cimerman, 2007). In response to this, increasing attention has been paid to the development of highfidelity clinical simulation and the role this may play in postgraduate education and learning
(Shapiro et al., 2004; Gordon and Buckle, 2009). Simulator-based training is well established in aviation
and other high risk industries where it is used for skills training and enhancing inter-staff communication
(Paver-Erzen and Cimerman, 2007). Healthcare is one of the few high-risk industries that has not yet Simulating Fidelity In Nursing Education Essay
fully embraced the incorporation of simulation into the primary and continuing education of healthcare
professionals (Shapiro et al., 2004). Patient simulators were first used medically in anaesthesia crisis
resource management and due to their benefits are now being increasingly used in the education of
qualified physicians, nurses and other AHP’s (Good, 2003).
High-fidelity clinical simulation involves treating a lifelike mannequin that produces realistic physiological
responses to interventions in a ‘real-time’ ‘real-life’ situation. The experience is viewed by peers and faculty
and the participants able to view a recording of their simulated scenario. Post simulation, participants all
engage in a debrief session, discussing reasoning and theories behind actions and reflecting on performance.
The simulation and debrief process permits a sequential increase in task complexity, unlimited repetition,
immediate feedback on action and enables learners to progress at their own pace (Good, 2003).
When combined with existing traditional training methods, simulation training for emergency department
staff and graduate nurses has been found to improve both technical and non-technical patient management
skills, enhancing learning and developing clinical proficiency (Gordon and Buckle, 2009). This leads us
to consider whether high-fidelity clinical simulation facilitates the transition between theory and practice,
facilitating deep learning and understanding at undergraduate level and assists in preparing students for the
reality of clinical practice?
Constructivist Learning Theories
To quote Henri Poincare, mathematician and physicist (1854-1912):
‘Science is facts; just as houses are made of stones, so science is made of facts. But a pile of stones is not
a house and a collection of facts is not necessarily science’.
Medicine and healthcare are sciences; however it is acknowledged that those students and clinicians who
can instantaneously recall the facts and theories do not necessarily make the best healthcare professionals.
Healthcare education has moved away from the traditional medical model, considering purely anatomy,
physiology and diagnosis of the problem to the bio-psychosocial approach, recognising not only the
underlying knowledge of the condition but also the impact emotional, behavioural and social factors have
on the context of the disease (Santrock, 2007).
It should be remembered at this stage that healthcare students are not just studying for a degree; they
are learning to do an important and responsible job (Ward, 2011). Various professional bodies emphasise
the importance of continuing professional development (CPD) throughout clinicians’ careers (General
Medical Council, 2006; Nursing and Midwifery Council, 2008; Chartered Society of Physiotherapy,
2005). At an undergraduate or pre-registration level we therefore need to ensure students are provided
with the opportunities to develop the skills to become competent and reflective practitioners of the future,
recognising that qualification is not the end of the learning process but merely the beginning, with their
degree providing the foundations to build knowledge and experience upon in their future clinical roles.
Constructivism involves the learner engaging in a joint experience with the teacher to construct and create
their own understanding of the experience. Constructivist learning theories extend from Vgotsky’s notion
of the ‘zone of proximal development’ (ZPD), that being the difference between the learners current ability
to solve problems independently and that which they can achieve with guidance and collaboration (Figure
1). Problem-based learning (PBL) is a constructivist approach frequently taken in the education
35 Simulating Fidelity In Nursing Education Essay
undergraduate healthcare professionals. Students are presented with a problem, usually a clinical scenario,
and are required to work in small groups to identify the issues emerging, draw upon the knowledge they
already have to address the problem and highlight further knowledge they need to acquire in order to
adequately solve the task (Khan and O’Rourke, 2004). PBL promotes a shift from didactive teaching
methods which involve transmission of knowledge to the students towards more engaging activities which
encourage students to construct their own knowledge and understanding (Khan and O’Rouke, 2004),
developing skills that will assist them with CPD and reflective practice throughout their training and
professional careers.
Another benefit of PBL is the opportunity for students to incorporate and link information they have
previously learnt, integrating basic science into the clinical scenario or problem to be addressed (Norman,
2005). Previous literature on mapping of knowledge structures suggest students enter into a situation with
a set of pre-learnt facts or ‘spokes of knowledge’. As learning takes place, these facts are built upon and
linked together forming ‘chains of knowledge’ which enable the student to reach their goal and successfully
understand the theoretical concept behind the problem (Kinchin et al., 2008). Clinical scenarios however
are seldom that straightforward. The human factors involved when treating a patient mean previously
learnt facts and chains of knowledge are not always relevant or prove untrue when dealing with ‘real-life’
scenarios. This is coupled by working in a team with individuals with differing backgrounds, knowledge
and understanding. Students then need to ‘grapple’ with these competing spokes and chains of knowledge,
which, as they develop meaning and situation specific context begin to form more complex ‘networks of
understanding’, enabling them to successfully select a solution to the given problem. (Kinchin and Cabot,
2010; Bradley et al., 2006; Kinchin et al., 2008).
Despite these benefits, PBL still does this in the context of small groups, discussing and theorising actions
and knowledge. Whilst this facilitates active engagement from students and clarifies understanding it does
not necessarily translate to improved patient care and outcomes which is considered a primary aim in
current healthcare. Activity theory on the other hand analyses and develops knowledge in relation to the
tools used, the rules of the community and the social and contextual factors in which the activity occurs
Figure 1: Zone of Proximal Development (taken from Simulating Fidelity In Nursing Education Essay

(Jonassen and Ruhrer-Murphy, 1999). Jonassen and Ruhrer-Murphy (1999) conclude the more embedded
the conscious thought processes are, the more meaning the learner attaches to the activity, deepening their
learning and developing understanding.
High-fidelity clinical simulation provides an ideal activity to construct learning from, providing students
with a ‘risk free’ environment (Good, 2003) to practice, explore and develop the theories and solutions they
have constructed during the PBL activity (Gordon and Buckley, 2009). It also considers the non-technical
skills such as team working and communication that are inexplicably linked to solving the problem if we
adopt an activity theory view. By participating in clinical simulation and acting out a scenario students gain
knowledge, which effects understanding, shapes future actions and creates the transformational processes
central to activity theory and a constructivist approach to learning (Jonassen and Ruhrer-Murphy, 1999),
thereby extending the learners ZPD.
Gordon and Buckley (2009) examined the effects of simulation on graduate nurse’s perceived ability and
confidence in responding to patient clinical emergencies. Fifty nurses participated in the study and were
filmed responding to simulated emergency situations. Results demonstrated significant improvements in
both practical skills such as managing breathing difficulties and performing defibrillation and non-technical
skills such as communication and resource utilisation. These are skills that it is undoubtedly difficult and
unethical to practice in ‘real life’ scenarios. Perhaps most interestingly 94 per cent of the participants
reported the post scenario debrief was the most useful aspect of the experience suggesting it is perhaps
the opportunity to review, pause, discuss and reflect on practice that is important to enhance learning and
development for future situations. Similarly, Shapiro et al. (2004) found a period of simulation training in
addition to a traditional didactic teaching programme resulted in a positive but non-significant impact on
team working amongst emergency department staff. These improvements occurred despite individuals
being familiar with problem-solving skills and working in high pressure environments, suggesting the
opportunity to practice in a low risk environment improves overall performance.
This may therefore highlight a role for high-fidelity clinical simulation in the training of undergraduate
healthcare students, providing a controlled environment to reflect on knowledge and practice, engaging
students in the discussion and exchange of knowledge with peers and experts, enhancing both learning and
the scholarship of teaching (Trigwell and Shale, 2004).
Conditions for Adult Learning
Like constructivism and activity theory, Habermans (1971), describes three conditions that are required
for adult learning to occur. These are context, meaning and reflection. As adults we have various levels
of prior knowledge and accepted facts that we draw on when presented with new concepts, these can
prove true or untrue depending on the context in which we use them. In order for adult learning to occur
we need to add meaning to the situation, which often involves reflection and the notion of ‘perspective Simulating Fidelity In Nursing Education Essay
transformation’ (Mezirow, 1981). Perspective transformation involves recognising and reflecting on the
impact past experiences have on the new experience and is a central function to adult education (Mezirow,
1981). The notion of reflection and perspective transformation is also evident in Kolb’s learning cycle
(1984) which is frequently referred to as a framework for students to structure their reflection around in
current healthcare teaching.
With consideration of the work by Habermans and Kolb it is clear to see how clinical simulation would
provide the opportunity for adult learning to occur (Figure 2). The ‘concrete experience’ of the simulation
task provides opportunity for the students to reflect on performance and outcome, drawing on prior
knowledge and experiences when discussing their actions, adding conscious meaning to the experience.
It also provides opportunity in the debriefing session to explore alternative theories or approaches to the
situation, potentially transforming students understanding or ideas to approaching similar tasks in the
Figure 2: Kolb’s Learning Cyclle (Kolb, 1984) annotated and related to high-fidelity clinical simulation
We often talk of a surface or deep approach to student learning. A surface approach involves rote learning
of material, often driven by short-term external pressures such as passing an exam. In comparison, a deep
approach to learning is established when students aim to find meaning and relations to similar domains
or other knowledge (Fyrenius et al., 2007). Two main categories are considered in relation to achieving
understanding; receiving and condensing information from available resources and sorting and sifting what
is relevant to know. In a deep approach to learning, students relate new information to prior knowledge
and experience, developing their own understanding of the material (Fyrenius et al., 2007). Students
who choose to build and develop knowledge in this way ensure learning becomes a dynamic, evolving
process where understanding is viewed as an opened ended event, constantly changing depending on the
environment, situation and task (Fyrenius et al., 2007). This idea of moving understanding also reflects
the perspective transformation described by Habermans and the reflection and abstract conceptualisation
reported by Kolb.
As providers of higher education for healthcare students we should aim to engage students in a deep
learning approach, enabling them to use their knowledge meaningfully in novel situations with patients
(Fyrenius et. al., 2007). Another central feature to adult education is enhancing students’ ability to
function as independent learners (Mezirow, 1981).In their discussion of the scholarship of teaching,
Trigwell and Shale (2004), suggest in order for students to learn and develop as independent thinkers they
need to be viewed as equal partners in learning, involving collaboration and sharing of information between
students and teachers in a two way interaction. Universities therefore need to provide students with the
appropriate opportunities, activities and forums to develop critical thinking and reflection skills, enabling
them to become independent learners both during and following their degree.Simulating Fidelity In Nursing Education Essay
(doing/having an
from experience)
(Planning / trying
what you have
Simulation Experience
Using previously
acquired knowledge to
address clinical scenario
Debrief Session
Students, peers and faculty
discuss actions, share
knowledge and reflect on
simulation exercise
Collaborative Meaning
Conclusions drawn from
group debrief session.
Understanding developed
and alternative strategies
Perspective Transformation
Simulation experience shapes
learning. Performance either
reinforced and repeated or
new approaches adopted to
trial in future.
Clinical simulation affords this collaboration and interaction. Having drawn on their knowledge and prior
understanding to address the problem the opportunity is then provided to interact with peers and teachers
in the debrief session, exploring and developing the concepts covered in the simulated exercise. As well
as promoting a deep approach to learning, reflection and perspective transformation, simulation may also
offer the opportunity to develop knowledge structures, moving from the previously described spokes and
chains of information to networks of understanding associated with advanced reasoning and expert status
(Kinchin et al., 2008).Simulating Fidelity In Nursing Education Essay
Novice versus Expert Status
Within the context of higher education students are often regarded a novices and academics as experts
with superior knowledge and performance in their subject areas (Bradley et al., 2006). The role of the
expert is to share with the novice their knowledge, enabling the novice to construct and develop their own
understanding of the subject. When looking at the structure of individuals’ knowledge frameworks experts
demonstrate networks of understanding incorporating various competing chains of knowledge, the most
appropriate of which is selected depending on the task and desired outcome (Bradley et. al., 2006). The
knowledge framework of novices on the other hand exists as spokes of previous information and facts that
create a state of ‘learning readiness’ (Kinchin et al., 2008), upon which chains of knowledge devised from
the experts teaching are constructed. In time the novice can begin to move and transform these chains of
knowledge, developing their own network of understanding (Kinchin and Cabot, 2010).
As a practitioner learns a skill they pass through five stages of development. These range from novice,
to advanced beginner, competent, proficient and finally expert (Dreyfus and Dreyfus, 1986). As they
progress through the stages, the learner becomes more aware of the interaction and outcome of their
activity in relation to the wider situation. There is a move away from a rigid adherence to the rules towards
an intuitive grasp of the situation, based on a deep tacit understanding and analytical approach (Kinchin
and Cabot, 2010). If the experts tacit knowledge is not made available to the student during the learning
experience they may struggle to grasp the topic and its relevance unless the expert spends time teaching
and explaining what has become intuitive to them (Kinchin et al., 2008).
It is recognised experts view a situation more holistically than a novice. For example a student or newly
qualified physiotherapist has a basic level of understanding and limited experience to aid in hypothesis
generation. The novice therefore will adopt a more structured approach using little situational awareness
whereas the expert will utilise more abstract concepts to solve a problem, demonstrating a holistic
perception of the situation (Bradley et al., 2006). Simulating Fidelity In Nursing Education Essay
Figure 3: The relationship between the three major knowledge structures (from Kinchin, 2008)
Certainly during healthcare education I do not believe it is possible to create ‘expert’ graduates as the
vast and rapidly changing domain of healthcare requires a commitment to lifelong learning and CPD. I do
believe however that our role as higher education institutes is to produce graduates who are of a competent
and proficient level, provided with the skills to cope with the crowdedness of information surrounding them
and approach situations holistically rather than as separate discrete tasks.
Engaging students in clinical simulation exercises may serve as a safe and efficient way of facilitating
development of these skills. Students are able to put theory into practice, exploring the links and conflicts
of previously learnt knowledge and theories in a safe environment where reality can be suspended and no
harm occurs to patients. Simulator-based learning enables the training agenda to be determined by the
needs of the learner, not the patient (Good, 2003) and provides the learner with an insight into the experts
network of understanding, tacit knowledge and holistic view of the situation during the post simulation
debrief which involves two way sharing of information between students and teacher.Simulating Fidelity In Nursing Education Essay
It was mentioned in the introduction to this essay that current methods of assessing medical and healthcare
students such as OSCE’s, MCQ’s and exams tend to promote surface learning approaches, assessing
students knowledge rather than proficiency in both the basic and complex tasks required in practice
(Murray, 2005). Whilst a comprehensive discussion on the role of high-fidelity clinical simulation in the
assessment of students studying healthcare related courses is beyond the scope of this paper it has become
apparent it may incur potential benefits.
If our overall objective is to produce healthcare professionals not only competent to practice at a basic
level but to develop as expert practitioners of the future we need to equip students with these skills and
assess them in these ways at university (Stefani, 2005). Clinical simulation as an assessment modality
has the potential to assess and reward competent and proficient students who have demonstrated a deep
approach to learning, using, transforming and re-presenting relevant university taught material in the
clinical context they are about to enter into as a qualified medic, nurse or AHP. Assessing deeper learning
and situation-specific use of knowledge promotes these actions amongst students during their studies. By
40 Simulating Fidelity In Nursing Education Essay
using clinical simulation in the assessment of the competent or proficient student we can align learning
outcomes, teaching activities and assessment methods, developing a ‘web of consistency’ and enhance the
constructive alignment of the curriculum (Biggs, 2003). This will hopefully improve teaching and learning
experiences for healthcare students and produce competent, thoughtful, professional and forward-thinking
healthcare professionals of the future (Ward, 2011) who are adequately equipped to take on the challenges
of the modern health care system and lifelong learning.
This paper has presented evidence for the role of high-fidelity clinical simulation in the education of
undergraduate and pre-registration medical and healthcare students based on constructivist theories of
Clinical simulation can be used to create a clinically realistic environment in which learning takes
precedence over patient care (Good, 2003). It uses activity theory to compliment and further develop
the concepts of PBL, providing students with the opportunity to work together to use and acquire the
knowledge necessary to solve a given task. The simulation experience and post session debrief provide an
interactive forum for students to use and transform their chains of knowledge to the beginnings of networks
associated with the expert status. It also provides a risk free learning environment which can progress at the
rate and direction desired by the student, developing both technical and non-technical skills essential for
effective patient care. Ultimately clinical simulation promotes learning that ‘is based on discovery guided
by mentoring rather than on the transmission of information’ (Boyer Commission, 1998), providing ideal
opportunities to promote and develop clinical reasoning and critical reflection skills necessary to become
independent learners ready to take on the challenges of the health care system and notion of lifelong
Clinical simulation is also likely to be beneficial in the assessment of competent and proficient healthcare
graduates, enhancing the constructive alignment of the curriculum and promoting deep approaches to
learning and studying.
It would be of interest to investigate the incorporation of high-fidelity clinical simulation into the
undergraduate education of medical, nursing and AHP students to formally examine the impact on the
quality of learning and the healthcare professional produced as a result.  Simulating Fidelity In Nursing Education Essay

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