1. Sofer, Dalia


This clinical activity is transforming nursing training and practice.


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Clinical simulation-defined by the National Council of State Boards of Nursing (NCSBN) as "an activity or event replicating clinical practice using scenarios, high-fidelity manikins, medium-fidelity manikins, standardized patients, role playing, skills stations, and computer-based critical thinking simulations"-has become an integral part of nursing education. In 2010, a national survey of prelicensure nursing programs conducted by the NCSBN revealed that 87% of respondents were using medium- or high-fidelity patient manikins in their curricula. And in 2014 a landmark national study, also conducted by the NCSBN, found no statistically significant differences in clinical competency or comprehensive nursing knowledge between students who had undergone traditional clinical experiences and those who had either 25% or 50% of their traditional clinical hours replaced by simulation. The NCSBN determined that nursing programs could substitute up to 50% of traditional clinical practice with simulation, provided they include "faculty members who are formally trained in simulation pedagogy, an adequate number of faculty members to support the student learners, subject matter experts who conduct theory-based debriefing, and equipment and supplies to create a realistic environment."

Figure. Nursing stud... - Click to enlarge in new window Nursing students interact with a manikin that talks and simulates symptoms in a mock ED simulation lab at Northeastern University School of Nursing in Boston. Photo (C) Melanie Stetson Freeman / Christian Science Monitor / The Image Works.

The NCSBN's 2014 study led to the development, a year later, of the NCSBN Simulation Guidelines for Prelicensure Nursing Education Programs, which are among the three best practice guidelines currently used by simulation programs. The other two are the International Nursing Association for Clinical Simulation and Learning (INACSL) Standards of Best Practice: Simulation-which provide "an evidence-based framework to guide simulation design, implementation, debriefing, evaluation, and research"-and the Society for Simulation in Healthcare (SSH) standards, through which simulation programs may receive accreditation and simulation educators may obtain professional certification.



In 1958, Norwegian doll manufacturer Asmund S. Laerdal, who had years earlier saved his son from drowning by pulling him out of the water and clearing his airways, was asked to develop a manikin for mouth-to-mouth resuscitation, with airways that could be obstructed and cleared, a head that could be turned, and a chest that would respond to inflation. By 1960, Laerdal had developed "Resusci Anne," the now-ubiquitous CPR manikin. (Today, his company, Laerdal, is among the leading producers of medical simulation and clinical training equipment.) Nearly a decade later, Sim One, the first computer-controlled patient simulator, created by Judson Denson and Stephen Abrahamson at the University of Southern California, allowed anesthesia residents to train in endotracheal intubation.


In the decades since those early prototypes, simulation has become integral to nursing education and practice, supplementing learning outside of the classroom or used as an instructional method to further explore such difficult subjects as end-of-life issues, critical illness, and cultural sensitivity. The skills that may be enhanced with the use of simulation include technical and functional expertise, problem-solving and decision-making competence, and interpersonal and communication skills.



"Simulation is a sophisticated teaching strategy, and has been around a long time," says Susan Gross Forneris, PhD, RN, CNE, CHSE-A, excelsior deputy director of the Center for Innovation in Simulation and Technology at the National League for Nursing (NLN). "But with the advent of high-fidelity manikins, the realness factor has changed and simulation has gained more ground. The question is, what are you trying to achieve? The desired outcome drives how much realism you need." Together with Laerdal, the NLN has launched Simulation Education Solutions for Nursing (SESN), which helps schools and programs-both undergraduate and graduate-to implement simulation training for nursing students. In addition, SESN ensures that programs are compliant with the three best practice guidelines (those of the NCSBN, INACSL, and SSH) and that they adhere to the specific requirements of their individual state boards of nursing, which determine, for example, how many hours of clinical practice may be substituted by simulation. "Some states are more prescriptive in their requirements, while others are looser," says Forneris. "It's a constantly evolving process."


Simulation training is not limited to students, and many programs exist to help practicing clinicians further their training or to assist hospitals to achieve such benchmarks as low infection rates and early identification and management of sepsis. For example, the Center for Medical Simulation (CMS), affiliated with Harvard University in Boston, provides courses for clinicians, health care educators, administrators, and managers, and consults with organizations on developing simulation programs. The training for clinicians focuses on teamwork, crisis resource management, and error prevention, in such specialties as anesthesiology, labor and delivery, emergency medicine, intensive care, and pediatrics. Nurses who participate receive a certificate of attendance, with credit hours that may be converted to CEs or CEUs.


Kate Morse, PhD, MSN, RN, associate director for educational leadership and international programs at the CMS, explains that in any simulation program course designs are influenced by multiple factors, including the INACSL standards and information from the Best Evidence Medical Education Collaboration, an international organization committed to the development of "evidence-informed education in the medical and health professions." Furthermore, she says, "when designing a simulation course or experience, expectations must be made clear: Is the purpose of the assessment summative or formative? What are participants being evaluated on, and what potential consequences are there?" Morse stresses that a psychologically safe learning environment is critical. At the CMS, consistent with best practices, simulation experiences are followed by a structured debriefing that may include video playback.


Also gaining ground are virtual simulation courses-which replicate real-life scenarios in virtual clinical environments-although, Forneris says, virtual "isn't a replacement for live clinical simulation. At least not yet." That may change in time. One recent literature review of 12 studies published between 2008 and 2015 found that online virtual simulation is at least comparable or even superior to traditional simulation methods and therefore has promise as a teaching and learning tool. However, it is not yet clear whether it's effective for diagnostic reasoning, and if it's best used as a teaching tool or an assessment strategy, or both.


Several factors have been driving the proliferation of simulation training, including an increase in the number of undergraduate nursing programs, which has led to more competition for clinical placement sites. Furthermore, to ensure patient safety, some acute care facilities have reduced the number of nursing students allowed on a patient unit at one time or restricted the activities students may perform. But another factor, Forneris explains, is that by transforming nursing education from content delivery to contextual learning, simulation offers students the kinds of experiences they need to safely transition into practice, and is encouraging faculty to change their pedagogic approach. "After experiencing a simulation session with students and doing the debriefing," she says, "many faculty have expressed feeling like they've really evolved. Rather than saying to students, 'I'll show you how to do this,' they give them a chance to perform. It's less show-and-tell." Debriefing sessions conducted after training, Forneris adds, are often transformational for students and faculty alike. "As nurses, we have long known how to have therapeutic conversations with patients. Then we realized, why not with students? Simulation has changed the conversation."-Dalia Sofer