1. Kubin, Laura PhD, RN, CPN, CHES
  2. Fogg, Niki MS, RN, CPN
  3. Elaine Wilson, C. PhD, RN, CPN
  4. Wilson, Jennifer DNP, RN, CPN

Article Content

Simulations that increase student exposure to multiple patient scenarios can provide opportunities for students to make clinical judgments, problem solve, and prioritize, which increases their readiness for clinical practice.1-3 This article describes a multipatient simulation innovation that strategically integrates blended individual and group activities to promote prioritization, clinical reasoning, and personal accountability.



Meeting the needs of today's rapidly changing society requires nurse educators to move from a task-based proficiency model to one that focuses on higher-level competencies including decision-making skills, which can be used across the entire spectrum of clinical practice and patient care settings.4 Employers expect new graduate nurses to enter the workplace able to communicate clearly, practice safely, and make sound clinical judgments while caring for numerous patients without the benefit of a long orientation period.5 However, new graduates largely enter the profession deficient in these competencies, fueled by limited experience managing multiple patients simultaneously.1-3,6 Simulation using multipatient scenarios can enhance readiness for clinical practice by promoting clinical judgment, problem solving, clinical reasoning, and critical thinking, despite the gaps in the literature regarding immediate and long-term outcomes, limitations, and optimal simulation design.1-3


Research has shown simulation is an effective method for teaching teamwork, critical thinking, prioritization, delegation, safety, clinical judgment, and communication.3,5,7-9 Group simulation enhances communication and collaboration skills, meets the needs of various learning styles, and can foster peer teaching. However, personal accountability and individual evaluation of decision making and clinical reasoning are limited.5 Individual simulation participation followed by convening in groups has been shown to enhance clinical judgment.8



This innovation addresses the limitations of single-patient group simulation designs. Clinical reasoning can be enhanced by using simulations that focus on individual participation, allowing the learner to proceed through the assessment, information gathering, and prioritization phases without interruption prior to debriefing. This simulation was created to promote students' development of individual clinical reasoning and faculty's ability to evaluate the individual student's performance.



The simulation is a summative experience with scenarios designed to align with didactic coursework. Prior to participation, students review didactic coursework related to recognition and nursing management of common pediatric concepts. Additional resources are available in the assessment area for students to use as they process the information.


Set in the pediatric emergency setting, a group of individual simulation scenarios allows 5 students to participate in the activity at 1 time. Faculty facilitate approximately 130 students per semester in the simulation over the course of 4 days (see Table, Supplemental Digital Content 1, Each student randomly selects 1 static patient scenario and is provided with a video or written report, background information, pertinent health history, and necessary resources. Each student assesses his/her assigned patient and completes a standardized patient report within a 30-minute time frame. Students ask faculty any information that could not be gathered from the patient medical record or during assessment of the simulator, such as pain level.


Students then move to the group deliberation phase where each student reports patient findings and suggests priority recommendations to peers using a standardized method similar to shift report. After all students report on their patients, the student group prioritizes all 5 patients based on acuity and makes final recommendations for patient care. This group activity portion strengthens the individual accountability because each student provides a report to their peers and shares their analysis and interpretations of findings. Following the group deliberation, a debriefing phase occurs during which a faculty member reviews the group's prioritization of the 5 patients from highest to lowest acuity, evaluates the group's recommendations, and guides the group to focus on key concepts. Students complete self-evaluations of their performance and peer evaluations of their group members in the collaborative prioritization sessions.



Students overall described the simulation as a favorable learning experience, noting it helped them identify gaps in their knowledge and strengthened their prioritization skills. Some students reported they were intimidated by the fact this was the first time they had to complete simulation scenarios alone and feedback was not immediately provided about the accuracy of their assessments; however, they also recognized the benefits of the activity. Students often reported they "learn more from this simulation than in an entire clinical day with only 1 or 2 patients."


Faculty reported greater insight into the clinical reasoning ability of students who may be more comfortable allowing their peers to talk or take the lead in group-only simulation settings. During deliberation and debriefing phases, faculty observed students professionally communicating with peers, advocating for patients, and effectively prioritizing patient acuity.



The blended simulation design allows nurse educators to assess the thought processes and clinical reasoning abilities of learners in a variety of situations. By design, the educator can assess the questions asked, the data gathered, and how the learner integrates the data to make conclusions and decide on prioritizations and actions. This method enables faculty to more accurately assess and evaluate all students participating in the simulations. Learners are able to self-assess whether the data they gathered were relevant, conclusions they made were accurate, and suggested actions were appropriate. Furthermore, students gain experience in professional communication, collaboration, advocacy, and accountability. The authors are currently collecting quantitative data to measure clinical reasoning and prioritization outcomes of this simulation.




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