Introduction

Many different educational strategies are being utilized to address the changing needs and challenges in nursing education. One strategy that has grown in popularity is the incorporation of simulated clinical experiences.1 Simulation-based learning experiences (SBLE) are activities that promote, improve, or validate a participant's response to a scenario that is mirrored to a real clinical situation.1 These activities expose a learner to a clinical situation and require the learner to utilize clinical reasoning to practice decision making, critical thinking, clinical skills, or develop new attitudes.2 Simulation is being utilized more frequently around the world in nursing education due to clinical site scarcity, increased nursing school enrollment, encouragement to use active learning strategies in the classroom, and to meet staff development needs.3-11

Nursing schools are having difficulties finding enough clinical sites to meet clinical education requirements.9,11 In the United States, the National Council for State Boards of Nursing (NCSBN) recently completed a study that suggests that placing students in SBLE for up to half of the required clinical hours can achieve similar learning outcomes to traditional clinical experiences.2 Boards of nursing and nursing schools have used these data to replace up to 50% of the required clinical hours in simulation learning.12-15 Increased use of simulation for clinical learning requirements has led to changes in faculty-to-student ratios.16

Meanwhile, calls for reform in nursing education are encouraging a radical transformation of undergraduate nursing education.17 Nursing graduates have long been considered under-prepared to care for complex patient health needs.17-19 Specifically, nurses have been cited as missing critical skills such as clinical decision making and clinical reasoning.20 Boards of nursing, international professional nursing education organizations, and nurse educators are responding to this call for reform by encouraging activities that require students to develop clinical reasoning and decision-making skills prior to graduation.20 Nurse educators are utilizing active teaching strategies, such as simulation in the classroom.20 However, faculty shortages paired with increasing student populations are placing more students in a single classroom. This increased classroom size is making educators utilize large group simulation teaching strategies. Large group simulations require the class to observe only a few active simulation participants.5,10

Health care facilities around the world have also begun utilizing SBLE to address staffing education needs.21 As patient care changes and becomes increasingly more complex, nursing staff are required to demonstrate and maintain competency.21 Simulation research is supporting the use of SBLE as an effective teaching strategy to address the educational needs of practicing nurses.8,22 Therefore, hospitals are using SBLE more frequently for continuing education requirements and staff training exercises.

As SBLE has become more popular, resources and manikin availability are not able to sustain the demand placed on simulation programs in nursing schools and health care facilities.3,4,16,23,24 To accommodate the growing demand, many programs have begun placing learners in non-participatory, or observational, roles. This observer role has been defined in many ways. Some researchers define the role as watching a live scenario performed by other students, while others view recordings of their own, other students, or expert behavior.25,26 However, for the purposes of this study, the observer role was defined as a generic role assigned to students whose assignment is to watch the scenario unfold and who has no active participation in the simulation scenario. The observer watches the simulation located within the simulation room, through a live video feed in a different room, or as pre-recorded scenarios viewed remotely. This role may be assigned as a tool to guide reflection while viewing the scenario and is involved in all simulation activities except scenario performance, (i.e. pre-briefing, debriefing).25-27

Simulation science is still investigating what learning outcomes can be achieved from observing the simulation experience. Learning outcomes have been defined as any measurable knowledge, skill, or ability acquired from participating in SBLE.28 A key concept in this definition is that learning outcomes must be measurable. A recent umbrella review suggests that students who participate in simulation attain cognitive, psychomotor, and affective skills.29 This same review found that the learning outcomes that have been measured in simulation participants have largely relied on self-reported instruments and surveys. Therefore, the review encouraged use of more valid and reliable instruments measured by trained, independent investigators to measure this learning.29 To address this problem, the International Nursing Association for Clinical Simulation and Learning (INACSL) created a repository of reliable, validated tools for use in simulation research; for example, there are tools to measure the cognitive skill of clinical judgment.30 However, all tools rely on observing student behavior and performance during active participation in the simulation to measure this cognitive skill.31-34 Therefore, researchers would not be able to use these measurement tools in simulation observers.

Presently, it is unknown if similar learning outcomes to those described above can be expected from learners who do not actively participate in the simulation. A previous systematic review investigated whether the use of observer tools impacted observer learning compared to observers who were not given a tool.9 However, there has not been a previous review completed that looks at a broad investigation of learning outcomes, measurement of the outcomes, and the gaps in simulation observer research. Therefore, a scoping review is proposed to identify and map the current extent and types of research relating to the observer role in nursing simulation. The results of the review will be used to highlight areas in need of further research, and to inform future studies by identifying outcomes and how they were measured.

Review question

What learning outcomes have been reported in nurses or nursing students participating in simulation while assigned to the observer role?

Inclusion criteria

Participants

The scoping review will consider any study that focused on any pre-licensure nursing students in a licensed vocational nursing, associate degree nursing, baccalaureate program, or the equivalent; students in a graduate (master's or doctoral) nursing education program; or practicing nurses (licensed vocational nurse, registered nurse, advanced practice nurse, or the equivalent). Literature that investigates simulation observation but includes other health care professions will be excluded from the study. Furthermore, inter-professional simulations where nurses participated as observers, but analysis of results were mixed with other professions in the observer population, will also be excluded. Finally, if participants were defined as observers but were involved in the simulation in a response-based role - as a family member, patient, or actively involved in the scenario - then these studies will be excluded.

Concept

The concept of interest for the proposed scoping review is learning outcomes. All reported outcomes of learning, including knowledge, skills, or abilities necessary for nursing, will be identified. Outcomes can include, but are not limited to, clinical readiness, critical thinking, test performance, academic performance, cultural awareness, skill performance, or emotional intelligence. Any study that investigated the observer role, but examined other non-related learning outcomes (e.g., satisfaction, preferences, stress, anxiety) will be excluded from this study. This scoping review is also interested in how these learning outcomes were measured; therefore, measurement will be another concept of interest. Measurement can include, but is not limited to, data gathered from qualitative interviews, exam scores, or approved simulation tools.

Context

This review will consider global studies that occur in a simulation scenario. The observer role in simulation includes vicarious learning - or those that investigate inactive participants - studies, large group classroom simulation, and observing one's own or expert behavior. Studies will be included for any simulation scenario topic related to nursing care. The SBLE could occur in a simulation lab, classroom, community, health care facility, or online setting viewing expert or the observer's own performance. Simulation-based learning experiences could last any amount of time, from quick drills to extended or repeated scenarios. Studies will be included whether or not observers participated in debriefing following the simulation activity. Studies that investigated observing a procedure in the hospital clinical setting, or where the observation occurred outside of a simulation experience, will be excluded from the study.

Types of sources

This scoping review will consider both experimental and quasi-experimental study designs including randomized controlled trials, non-randomized controlled trials, before and after studies, and interrupted time-series studies. In addition, analytical observational studies including prospective and retrospective cohort studies, case-control studies, and analytical cross-sectional studies will be considered for inclusion. This review will also consider descriptive observational study designs including case series, individual case reports, and descriptive cross-sectional studies for inclusion.

Studies that focus on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, qualitative description, action research, and feminist research will also be considered. Systematic reviews that meet the inclusion criteria will also be considered, as will text and opinion papers.

Studies published in English will be considered. All studies will be considered regardless of publication date.

Methods

The proposed scoping review will be conducted in accordance with JBI methodology.35

Search strategy

The search strategy will aim to locate both published and unpublished studies. An initial limited search of MEDLINE was undertaken to identify articles on the topic. The text words contained in the titles and abstracts of relevant articles, and the index terms used to describe the articles were used to develop a full search strategy for CINAHL (see Appendix I) The search strategy, including all identified keywords and index terms, will be adapted for each included information source. The reference lists of all studies selected will be screened for additional studies.

Information sources

The databases to be searched include JBI Database of Systematic Reviews and Implementation Reports, Cochrane Central Register of Controlled Trials, ProQuest (Nursing and Allied Health), Embase, ERIC, CINAHL, and MEDLINE. The search for unpublished studies will include ProQuest Dissertations and Theses.

Study selection

Following the search, all identified citations will be collated and uploaded into EndNoteX8 (Clarivate Analytics, PA, USA) and duplicates removed. Titles and abstracts will then be screened by two independent reviewers for assessment against the inclusion criteria for the review. Potentially relevant studies will be retrieved in full and their citation details imported into the JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI; JBI, Adelaide, Australia).36 The full text of selected citations will be assessed in detail against the inclusion criteria by two independent reviewers. Reasons for exclusion of full-text studies that do not meet the inclusion criteria will be recorded and reported in the systematic review. Any disagreements that arise between the reviewers at any stage of the study selection process will be resolved through discussion, or with a third reviewer. The results of the search will be reported in full in the final systematic review and presented in a Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews (PRISMA-ScR) flow diagram.37

Data extraction

Data will be extracted from papers included in the scoping review by two independent reviewers using a data extraction tool developed by the reviewers. The data extracted will include specific details about the population, concept, context, study methods, and key findings relevant to the review objective. The draft data extraction tool will be modified and revised as necessary during the process of extracting data from each included study. Modifications will be detailed in the full scoping review report. Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Authors of papers will be contacted to request missing or additional data, where required.

Data presentation

The extracted data will be presented in diagrammatic or tabular form in a manner that aligns with the objective of this scoping review. A narrative summary will accompany the tabulated results and will describe how the results relate to the review's objective and question.

Appendix I: Search strategy for CINAHL

References