Critical Thinking, High-Fidelity Simulation, Interactive Case Study, Practical Nursing Education



  1. Hudson, Sue
  2. Penkalski, Melissa R.


Abstract: There is a gap in the literature regarding how simulation affects critical thinking skills for practical nursing students. A quasi-experimental two-group pretest-posttest study was conducted to determine the effects of high-fidelity simulation and interactive case studies on critical thinking scores of 29 practical nursing students. Both interventions had significant results (p = .001) between pretest and posttest; however, significance was not found regarding posttest scores between the high-fidelity simulation and interactive case study groups. Identifying pedagogical strategies that increase critical thinking skills for certificate-seeking practical nursing students is necessary to provide excellent nursing care and promote better patient outcomes.


Article Content

It remains unclear if the critical thinking (CT) skills nursing students learn through simulation experiences transfer into real-world settings. Furthermore, there is little data in the literature regarding the use of simulation by practical nursing students (Lee & Oh, 2015). Clarifying the effects of simulation on CT in practical nursing students and identifying effective teaching and learning strategies are necessary to provide high-quality nursing education. The first objective of this quantitative, quasi-experimental research study was to evaluate the effectiveness of high-fidelity simulation (HFS) and interactive case studies (ICS) as teaching strategies for practical nursing students. The second objective was to determine if HFS produced higher CT scores compared to ICS. Because of the costs associated with HFS, the researchers wanted to determine if other, less costly, pedagogical strategies resulted in similar outcomes.



A cross-sectional, two-group, pretest-posttest study was used to examine causality in CT. After institutional review board approval was received from the university and a letter of support was obtained from the administrator of the technical college where the study took place, practical nursing students were invited to participate in this research study. According to Kolb (1984), learning is a continuous process in which the learner transforms experience into existing cognitive processes, thus changing how the person thinks or behaves. Benner's model of skill acquisition in nursing describes the process of skill acquisition as the nurse moves from novice to expert (Benner, 1984). These theories provided the framework for understanding how students use HFS and ICS to acquire CT skills and transfer those skills into practice.


The sample consisted of 29 practical nursing students enrolled in a fundamentals nursing course: 15 in the HFS group and 14 in the ICS group. Groups were chosen randomly by coin toss. At the time of the study, students were nearing the end of the first semester in a three-semester practical nursing program.


The HFS addressed fundamental concepts paralleling the knowledge base at the students' current course level; the scenario was chosen from published valid and reliable scenarios incorporating best practices in simulation education. Students in the ICS group were given a paper-and-pencil case study chosen from the assigned text for the course. The International Nursing Association for Clinical Simulation and Learning (INACSL) Standards of Best Practice: SimulationSM Simulation Design (INACSL Standards Committee, 2016) was used to implement the respective simulations. Both the simulation and the case study were followed by debriefing using the Promoting Excellence and Reflective Learning in Simulation debriefing method. Debriefing allowed the facilitator to reinforce concepts and clarify any uncertain issues. Each method took 50 minutes to complete.


Students rotated through the HFS in groups of four. Students blindly chose an index card to determine the role they would play: primary nurse, secondary nurse, medication nurse, or observer/family member. The facilitator gave the students verbal report; students then began care of the simulated patient. For the ICS, students worked in groups of four in a room separate from the simulation laboratory to problem-solve and answer questions on a sheet of paper. Minimal direction was given by the instructor until the ICS was complete.


The Assessment Technologies Institute (ATI) fundamentals specialty examination was used for the pretest and posttest. The Kuder-Richardson Formula 20, used to calculate reliability of items for this test, was reported at .70 (ATI, 2014). Descriptive statistics, including mean and standard deviation, were used on demographic data to identify variability. The chi-square test was used to compare demographic characteristics between groups with respect to age, gender, ethnicity, and prior HFS and ICS experience; significance was set at p < .05. Data analysis was performed using Statistical Package for the Social Sciences Version 22 software. A paired t-test was used to evaluate mean test scores between pretest and posttest; confidence intervals were constructed around mean differences to determine the estimate of effects.



The results of this study indicate that both educational interventions were successful in increasing CT scores in practical nursing students. Statistical significance (p = .001) was found between pretest and posttest scores following both interventions. Posttest scores were higher for the HFS group, but results were not statistically significant as mean scores were similar between the groups: HFS = 60.6 percent, ICS = 58.9 percent. The HFS group scores rose only 5 percent, whereas the ICS group had a 13 percent increase in CT scores. With regard to group comparison, the only statistical significance found between groups was previous case study experience. This was expected due to the greater availability of paper-and-pencil case studies.


Sample Demographics

The average age of the study group was 28; 3 male and 26 female students participated. Ninety percent of the participants reported their ethnicity as white; 7 percent were Hispanic, and 3 percent did not respond. Seventeen percent of students reported previous experience using HFS with a manikin (83 percent, no experience); 24 percent had previous experience with ICS (76 percent, no experience). The groups, overall, were similar with respect to all variables, excluding previous case study experience.


CT Scores

Prior to and immediately following the HFS and ICS interventions, students took an ATI customized examination and received a CT score (possible scores ranged from 0 to 100 percent). Sixteen questions covered clinical judgment/CT in nursing; four questions covered foundational thinking in nursing. The overall pretest mean group score was 50.6 percent; the overall posttest score was 59.8 percent, indicating an overall increase of 9.2 percent. Overall pretest scores ranged from 25 percent to 75 percent; overall posttest scores ranged from 40 percent to 80 percent. A paired t-test was used to compare pretest and posttest data; significance was noted at p = .001.



This study identified effective pedagogical strategies to enhance CT skills in licensed practical nursing students, thus validating implementation of simulation into the nursing curriculum and providing evidence to support transfer of knowledge into practice. The nursing literature shows increasing support for simulation as a means to transfer knowledge into real-world settings and prepare nursing students for clinical practice (Hayden et al., 2014). The National League for Nursing (2015) promotes the integration of simulation into the nursing curriculum, noting that a lack of clinical sites poses a serious problem for nursing schools across the United States. Current research supports substituting up to half of traditional clinical hours with simulation (Hayden et al., 2014).


The results of this study indicate that both HFS and ICS are effective teaching strategies for increasing CT skills in practical nursing students and are inconclusive regarding HFS as the superior pedagogical strategy. Furthermore, there is a question of costs. The paper-and-pencil case study textbook and corresponding scenario used for this study cost approximately $100. Compared to the large costs associated with the purchase of high-fidelity manikins and staffing simulation laboratories, less expensive teaching strategies may be considered a valid alternative. Smaller technical colleges may be unable to afford the large costs associated with implementing simulation into curricula.


Limitations of this study include using a nonprobability convenience sample of nursing students in one practical nursing program. The small sample size and lack of diversity in the sample limit the effect size and generalizability of findings. A mixed-method study design for future research may help strengthen results by collecting data regarding student satisfaction with educational interventions. Increased student engagement and satisfaction have been reported with HFS (Hayden et al., 2014; Smith & Roehrs, 2009; Weaver, 2011), which may make learning more meaningful and produce better student outcomes. Further studies regarding the effects of simulation on CT in practical nursing students are needed. It is crucial for nursing education to bridge the gap between what students learn in the classroom with practice in the clinical setting. As change agents, nurse educators must choose the most practical and effective pedagogical strategy for students, thus improving overall patient care.




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