The use of simulation for experiential learning has increased greatly in the past decade, especially since the Institute of Medicine report recommended it as a means to improve patient safety.1 In addition, the National Council of State Boards of Nursing endorsed up to 50% of clinical experiences could include simulation experiences.2 Now, more than ever, simulation learning is being used in light of the COVID-19 pandemic. For many academic settings, clinical experiences were completely closed down because of the pandemic. This required development and implementation of innovative methods of teaching to ensure students would continue to be engaged in experiential clinical learning and apply theory to practice.
Simulation includes the use of a variety of methodologies including high-fidelity manikins, procedural task trainers, standardized patient actors, and a variety of computer-based applications. Initially, the purpose of simulation was to primarily teach skills and allow evaluation of those skills. In more recent years, there has been interest in the efficacy of simulation experiences on problem solving and critical thinking. Simulation should be viewed as "a teaching technique that includes experiential learning with planned and facilitated debriefing that aims to enhance each learner's engagement with the content and improve the ability to transfer knowledge, skill and attitudes to clinical environments."3(p270) The overarching goal of each simulation experience is to optimize a learning environment and case scenario to provide a safe learning environment for students to take risks allowing for emotional and psychological needs of the learner.4 Prebriefing and debriefing are vitally important as learners are guided to understand the simulated environment and intent of the simulation in the prebrief and then, post simulation, provide the opportunity to reflect on and explore how the simulation experience impacted their knowledge, skill acquisition, and attitude under the expert guidance of faculty.
Simulation, as a teaching technique, is integrated not only in nursing curricula but also in clinical settings as clinical nurse specialists and nurse educators are charged with teaching new skills and integrating best practices. Traditional clinical experiences often do not include many of the day-to-day experiences an advanced practice nurse would encounter, so simulation experiences can be planned by faculty to fill those gaps. For example, management of chest pain, pulmonary embolism, and other emergent clinical situations can be presented to students via simulation. This allows students to make decisions and apply theoretical content in a low-risk environment without patient harm. Because there are so many varying methods to deliver experiential learning via simulation, it is timely to develop evaluation projects to measure the effectiveness of simulation methodologies that demonstrate competency is achieved and that students are exhibiting evidence of critical thinking and clinical reasoning. Objective methods of evaluation, both formative and summative, need further development to ensure the simulation experience is delivering the right amount of content and the participant leaves the experience with objectives met.
Several studies have examined the impact of simulation-based learning on learner satisfaction and learning outcomes (knowledge, skills, and attitudes). There has been more evaluation of simulation learning at the undergraduate educational level, although many studies can be appropriately replicated with advanced practice nurses. In the meantime, there continues to be emerging science addressing advanced practice nursing simulation education. In a systematic review by Warren et al5 that examined the effectiveness of simulation-based education on satisfaction and learning outcomes in nurse practitioner education, the authors found that the use of high-fidelity simulation resulted in student perception of better understanding of theoretical content and students were better able to connect evidence to practice. Of the 10 studies in this review, all but one showed that self-efficacy as an attitudinal measure was increased among students. One study in the review designed to measure critical thinking found that high-fidelity simulation helped students improve some of the critical thinking behaviors on the measurement tool. Students were able to integrate and apply essential components of clinical cases in a focused problem-solving manner compared with face-to-face, role-played sessions.
In another review, Pittman6 summarized the literature with advanced practice students and simulation learning. This author identified the levels of simulation from role playing to complex hybrid simulations using both standardized patient actors and high-fidelity manikins and also presented an innovative program for family nurse practitioner students. Formative and summative learning experiences were described. Summative assessments evaluate a student's competence on essential behaviors and attitudes at the end of a course or program and often are incorporated into the final grade. Formative assessments allow the student to complete a simulation, and the faculty can assess the student's current thinking about a behavior, skill, or knowledge set and then help the student to identify the gaps in their understanding. These gaps can then be addressed to improve the student's performance.6
In many cases, both psychomotor and communication skills were integrated into the simulation activity to reinforce patient-centered care. As simulation in advanced practice continues to evolve, emphasis on effective communication especially when delivering difficult news, interprofessional communication, and communication using telehealth will need to be explored more comprehensively to evaluate the benefit and growth in student behaviors. In acute care settings where collaborative practice is imperative, developing complex case management scenarios with other members of the interprofessional team is important for faculty and clinical settings to consider.
The National League for Nursing and others have developed evaluation tools for simulation experiences for undergraduate education. At the advanced practice level, checklists used for Objective Structured Clinical Examinations are very helpful to determine the psychomotor and some aspects of communication that students have mastered. However, more work needs to be done to create effective evaluation tools that measure competency in communication, critical thinking, and clinical reasoning. It is one thing to present theoretical content with experiential learning, but what competencies are actually attained? How far have we come to ensure application of theory to clinical practice, thus reducing the theory-practice gap? We need to develop better tools to measure the effectiveness of the simulation activities that are developed, and now is the perfect time as faculty and clinical nurse specialists are developing innovative simulation activities. In addition to developing tools, process change projects or research needs to be conducted to test the reliability and validity of these tools so there can be more standardization of delivery of simulation activities. Finally, to build on the current body of simulation science in advanced practice, the following implications for research should also be considered:
1. Dose frequency and duration of encounters to ensure competency.
2. Examination of repetitive encounters over certain periods to improve knowledge retention.
3. Cost analysis including equipment, space, time, and salaries to compare different educational approaches.
4. Development of effective models of curricular integration to ensure simple to complex simulations that build upon increasing abilities to problem solve and critically think and engage in interprofessional evidence-based practice.
In conclusion, now more than ever, simulation strategies are being developed and used to deliver content in a time where clinical sites and experiences are limited, because of both competition for those sites and the pandemic. As these methodologies are being developed, they need to be tested and disseminated so the body of science in advanced practice simulation can grow and we can ensure preparation of advanced practice providers to serve in this current complex healthcare environment.
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