Simulation in Nursing

BY MICHELE WOJCIECHOWSKI

In both practice and education, simulation in the nursing field has improved everything from treatments to patient outcomes.

Simulation—it’s something that nurses first encounter while

still studying in nursing school, but that’s not where it ends. Experienced nurses continue to use simulation, for example, to improve practice, communication between health care providers, the cooperation between interprofessional teams, and to teach/learn new techniques.

Before we explore its importance, let’s first understand what simulation is and the kinds that are being used today.

Imitation—the Safest Form of Practice

“Health care simulation is the imitation or replication of patient care situations for the purposes of education, assessment, and/ or research to enhance patient safety and quality patient care delivery,” says Michelle Olech Smith, DNP, RN, CHSE (Certified in Health Care Simulation by the Society for Simulation in Health Care), the program director of simulation at Northwestern Medicine Central DuPage & Delnor Hospitals.

Simulation also helps build confidence and competence in the nurses who are learning with it, says Celeste M. Alfes, DNP, MSN, MBA, RN, CNE, CHSE-A, FAAN, co-editor of Clinical Simulations for the Advanced Practice Nurse: A Comprehensive Guide for Faculty, Students, and Simulation Staff. “Simulation has become a widespread methodology because it is a hands-on learning strategy

that engages all sense of the learner,” says Alfes, who is also an associate professor and director of the Center for Nursing Education, Simulations, & Innovation at the Frances Payne Bolton School of Nursing at Case Western Reserve University. “During the COVID-19 crisis, simulation has become a tremendous tool for faculty and learners alike.”

“Simulation is an effective strategy in acute care because it prepares staff for high-risk situations that may be encountered infrequently,” says Joni L. Dirks, MSN, RN NPD-BC, CCRN-K, manager of professional development at Providence Health Care.

With simulation, those involved can slow down the learning, ask students to reflect on what they’re doing, and even stop what’s going on if students want to ask clarifying questions, says Jean S. Coffey, PhD, APRN, FAAN, director of the Plymouth State University Nursing Program, who has taught simulation in several nursing programs.

Simulation also provides nurses and nursing students with the opportunity to fail—in a safe environment—due to their inexperience with the procedure, without putting an actual patient in danger, says Cindy Cain, DNP, RN, CNS, CCRN-K, clinical practice specialist, the American Association of Critical-Care Nurses (ACCN). “They can practice clinical responses or high-risk skills in an expertly guided setting with feedback for improvement.”

www.minoritynurse.com www.dailynurse.com www.springerpub.com 19

Our experts identify the following as the most common types of simulation:

• Low-fidelity manikins: These tend to be used by nursing students to practice skills such as taking vitals, giving bed baths, and other types of care.

• High-fidelity manikins: These life-like manikins are computerized and can be programmed to talk and respond to students’ questions, as well as with physical characteristics like coughing and blinking. They can be programmed to exhibit clinical symptoms like trauma, cardiac arrest, maternal hemorrhage, and malignant hyperthermia.

• Training devices: These look like individual pieces of anatomy and students use them to practice specific skills like IV training on an arm.

• Standardized patients: People, often hired actors who have been trained in responding to various clinical scenarios and settings. Students practice their interviewing skills and nonverbal/ verbal communication skills.

• In situ: Coordinated simulations that happen in an actual clinical setting.

• Computer-based/virtual programs: Various software programs use interactive avatars and case studies to create different scenarios. Some of these include pre- and postquizzes to test students’ know-how.

Use in Nursing Education

Because students can use it without fear of hurting someone, simulation is essential, says Nancy A. Mimm, DNP, RN, MSN-BC, APHN-BC, assistant professor at Harrisburg

University of Science and Technology. In addition to being certified in clinical simulation, Mimm also heads the MSN program. “It is well known that students learn from their mistakes, which helps them avoid them in the future,” Mimm points out. “Simulation provides hands-on or tactile learning opportunities for students that cannot be achieved during a lecture.”

Simulation also provides educational opportunities when clinical sites aren’t available. “In nursing education, despite the need for more nurses in the practice setting, over 75,000 qualified applicants were not accepted into baccalaureate and graduate nursing programs in 2018 due to lack of faculty and classroom space. However, one of the biggest reasons was lack of clinical sites,” explains Julie Stegman, Vice President, Nursing Segment, Health Learning, Research &

Simulation also helps build confidence and competence in the nurses who are learning with it, says Celeste M. Alfes, DNP, MSN, MBA, RN, CNE, CHSE-A, FAAN, co-editor of Clinical Simulations for the Advanced Practice Nurse: A Comprehensive Guide for Faculty, Students, and Simulation Staff.

Practice at Wolters Kluwer. “Additionally, because of the increasingly complex health care setting, students may not have the opportunity to ‘practice’ appropriately. Evidence suggests that only 23% of new graduates have entry-level competencies, and many of the errors related to patient safety are caused by ineffective clinical judgments. These gaps in nursing practice of new graduates are attributed to ineffective communication, the complexity of the clinical environment, lack of knowledge about patient care, and lack of experience in working in teams.”

Coffey states that simulation can also helped advanced nursing students. “Simulation provides the opportunity to synthesize their learning and apply it within a simulated patient scenario,” she says. “The group debriefing at the end of any simulation helps the students all learn from each other and think about how they approached the situation and what might go differently next time they are in the situation.”

Some nursing schools like Plymouth State University have their own simulation centers on site. “This provides us the opportunity to run simulation

20 Nurse Practitioner Week Special Issue | NOVEMBER 2020

scenarios all semester and offer time for open lab to support students practicing skills such as inserting a catheter. Each nursing course and clinical class incorporates simulation into their lesson plans. The novice nurses learn how to take vital signs and give bed baths in the lab. The juniors learn about pediatric diabetes and respiratory problems. They also participate in a Social Determinants of Health lab focused on the impact of poverty on individual and community wellbeing,” explains Coffey. “In the senior year, there is a disaster lab with a mock explosion. Standardized patients from the theater department participate in the lab, in moulage that looks like actual wounds and burns. The students triage the victims to get care or move to the morgue. These labs help the students to

learn to provide wholistic care for their patients. It also provides them an opportunity to test themselves in a very highpressure situation with no risk for patient harm.”

Other schools are in the process of building simulation labs. “Harrisburg University will have a high-fidelity virtual simulation environment that we will use to teach nursing, health professions, and other community partners using human simulation,” says Mimm.

Simulation in nursing education programs yields good results. “A survey of the Essentials of Critical Care Orientation users showed an 83% increase in nurse recognition of stability changes in patients, a 73% increase in knowledge of evidence-based best practices, and 72% of the nurses who took the course reported significantly higher confidence in applying the concepts of critical care nursing (AACN, 2020),” says Cain.

“It is used most-often to promote the confidence and accuracy of clinical skills. One example is practicing patient resuscitation or advanced assessment skills used by advanced practice nurses, such as Nurse Practitioners, Clinical Nurse Specialists, or Nurse Anesthetists,” says Cain.

Practice Makes Perfect

Once nurses are practicing, they work with patients. So why do they need to use simulation?

“It is used most-often to promote the confidence and accuracy of clinical skills. One example is practicing patient resuscitation or advanced assessment skills used by advanced practice nurses, such as Nurse Practitioners, Clinical Nurse Specialists, or Nurse Anesthetists,” says Cain. “It has been shown to build a nurse’s confidence, prioritization, decision-making, clinical judgment and critical thinking skills.”

“One of the most important aspects of using simulation in ensuring the nurses learning have an opportunity to debrief, ask questions, and identify opportunities for improvement,” states Cain.

Mimm says that using simulation in practice is necessary for professionals who want to have the best possible outcomes in different settings. “For example, simulation is used to practice low-volume, higherrisk situations like a postpartum hemorrhage after a woman delivers a baby. This allows the team of providers to practice that scenario even though they might not see it regularly,” says Mimm. “Nurses learn many different things with simulation; it allows them to work critically and think through the process of caring for this patient before they ever experienced it in person. They can practice the skills and interventions that they need to use to achieve the best outcomes and immerse themselves in the emotions they will experience during a highly stressful situation. That way, they feel more.”

www.minoritynurse.com www.dailynurse.com www.springerpub.com 21

Mimm says that using simulation in practice has reduced medication and clinical errors, improved patients’ understanding of their plans of care, and also improved discharge needs and follow-up needs.

Olech Smith says that simulations in the clinical environment have additional benefits. “In situ simulation allows for the recreation of events to observe, modify, and evaluate health care,” she explains. “This may include discovering latent system hazards before they impact patients and helps us understand and reinforce appropriate actions and resources.”

While Dirks points out that there isn’t a ton of research on simulation’s impact on patient outcomes, she says, “We’ve encountered a number of process

improvements based on staff experiences during the simulations. For example, we identified role confusion regarding management of the airway during different phases of resuscitation, which led to clarification and an identified hand-off between staff,” she says. “We have also found gaps in knowledge related to use of equipment and logistics issues for obtaining supplies on off-shifts.”

Nevertheless, Cain says there is some research to back the benefits of using simulation. “A number of studies have shown

an increase in the nurses’ ability to recognize deterioration in patient condition and an overall decrease in adverse patient outcomes,” she says. One is “Simulation in Nursing Practice: The Impact on Patient Care,” a 2013 study published in the Online Journal of Issues in Nursing.

Simulation also helps people from various health care fields learn to work together. “Simulation is now recognized as an effective tool for engaging interprofessional teams and evaluating clinical processes. For example, instead of having each profession practice their skills in isolation, we pull the emergency response team together and put them through the drill,” says Dirks. “They learn about each other’s roles and how to communicate

“Simulation is now recognized as an effective tool for engaging interprofessional teams and evaluating clinical processes. For example, instead of having each profession practice their skills in isolation, we pull the emergency response team together and put them through the drill,” says Dirks.

with each other.”

In her 2019 Critical Care Nurse article “Effective Strategies for Teaching Teamwork,” Dirks writes, “Providing opportunities to apply teamwork during simulated scenarios or other group activities allows team members to identify areas for improvement and recognize the value of working collaboratively to achieve goals.”

During the pandemic, being able to do online simulations has allowed them to continue. Dirks says that their simulations have transitioned to an online format allowing staff to view

During the pandemic, being able to do online simulations has allowed them to continue. Dirks says that their simulations have transitioned to an online format allowing staff to view a video of a clinical scenario. “Participants pause the scenario and respond to questions to develop a plan of action. A facilitator then debriefs the group using a Teams meeting.”

a video of a clinical scenario. “Participants pause the scenario and respond to questions to develop a plan of action. A facilitator then debriefs the group using a Teams meeting.”

In order to make sure that simulations are successful and effective, facilities need to make sure that what they’re offering follows best practices. Alfes says, “Some of the best resources for best practices are the Society for Simulation in Healthcare, the International Nursing Association for Clinical Simulation and Learning, and the National League for Nursing. Coffey says that their nursing program—much like others—asks students to complete simulation-specific evaluations. “These evaluations inform our simulation plans,” she says.

“You need to have people who are experts in simulation and debriefing orchestrating the simulation to ensure the students or practicing nurses will have a successful experience,” says Stegman.

Looking to the Future

Our sources agree that virtual reality—which is already being used in many facilities and nursing schools—is the wave of the future.

“This rather new method of simulation allows learners to be immersed in a virtual environment that can be

interacted with a seemingly real and physical way, using a head-mounted display,” says Olech Smith. “This can include as many senses as vision, hearing, touch, and even smell.”

Virtual reality simulations are currently being used, including examples like fiber-optic bronco scope for airway management, ultrasound diagnosis, and endoscopic and laparoscopic surgery. It’s also being used to allow students to walk through a specific organ like the heart as they learn anatomy and physiology,” says Mimm. “I perceive nursing education simulation to continue to grow and develop. Professors will be able to use simulation in almost every part of their teaching, including online as students social distance. Simulation truly is the missing part of nursing and health profession education because it allows students to practice without doing harm to the patient.”

Michele Wojciechowski is a national award-winning freelance writer based in Baltimore, Maryland. She loves writing about the nursing field but comes close to fainting when she actually sees blood. She’s also author of the humor book, Next Time I Move, They’ll Carry Me Out in a Box.

www.minoritynurse.com www.dailynurse.com www.springerpub.com 23