1. Hall, Laura C. DNP, RN, CNL
  2. Gatto, Susan L. PhD, RN
  3. Lefevre, Laura BA
  4. Murphey, Tyler BS

Article Content

Nursing education programs often struggle to promote student engagement in the classroom when using traditional lecture-style delivery. Unengaged students struggle to find ways to apply abstract classroom concepts to clinical scenarios, which ultimately can pose a threat to patient safety.1 Nursing programs need time-efficient and cost-effective techniques to give students opportunities to be engaged and apply abstract classroom techniques that require critical thinking and clinical decision-making.


A common technique faculty use to keep students engaged is clinical simulation, which requires student participation in a clinical scenario involving direct interaction with human simulators. Another common technique is unfolding case study simulation scenarios, which change as students use critical thinking to make real-time clinical decisions. Debriefing these experiences allows students to imagine a variety of future implications that directly affect their actions.2


Clinical simulation increases student engagement and realistic practice opportunities; however, simulations typically only engage small groups of students. While students report being satisfied with these types of experiences, simulation is time intensive as multiple groups of students need to carry out the same, or similar, exercises. Preparing more practice stations, while more efficient, can be unrealistic as faculty and equipment resources are limited and costly.


Clinical simulation experiences designed for larger groups would engage many students in practicing critical thinking and clinical decision-making without patient risk. Live Interactive Classroom Simulation (LICS) is an unfolding case simulation that is unique as it enables large groups of students to be engaged when making clinical decisions at the same time LICS is a time-, cost-, and resource-efficient teaching strategy that engages students in clinical decision-making in a traditional classroom setting.


LICS Development

LICS was developed to challenge students to apply critical thinking skills and make clinical judgments about basic safety and infection control concepts. Course objectives and student learning outcomes were reviewed for alignment with the simulation. This approach allowed all students to view the simulation at once and make decisions as one cohesive group. The classroom provided ample space for this to occur.


Preparation for the LICS scenario consisted of not only developing the scenario but also preparing faculty to understand their prescribed role in the simulation. Nursing faculty, acting in the roles of nurse and patient, were given guidelines concerning how to proceed during the scenario. Faculty practiced how the scenario would begin but understood their following actions would be driven by student responses to the unfolding scenario. The simulation room was set up to demonstrate common hospital safety issues and concerns. The only preparation required of the students was a preclass reading assignment related to patient safety and infection control. The course instructor designed a Kahoot quiz to determine student options for subsequent nursing actions or decisions.


The course instructor facilitating the class provided background information on the patient and role of the nurse to the students. In this particular scenario, the patient was an elderly woman in a hospital room waiting to have vital signs taken. This patient was on fall precautions due to a history of falls. Two instructors, acting the role of nurse and patient, were located outside the classroom in the simulation room. Equipment required for this scenario consisted of audiovisual equipment in the classroom and a video camera with a closed system in the simulation room. LICS required students to make decisions for the nurse who was caring for the patient in the simulation room down the hall.



As the simulation began, students were given background information on the patient. As the nurse entered the patient's room to take vital signs, a live feed of the unfolding simulation was broadcast into the classroom for student viewing. An audience response system (Kahoot) was used to poll students to determine the action of the nurse. After the students were oriented to the patient and the scenario, the first question asked was: "What should the nurse do first upon entering the patient's room?" The students had to choose between checking the patient's identification and performing hand hygiene. The majority vote was then used to determine the nurse's action. The nurse implemented the selected action and the patient reacted to it. After each nursing action and patient reaction, the students were polled again with the question, "What should the nurse do next?" Students were given 2 to 4 nursing actions to choose from. The final question for the students was: "Before exiting the patient room, what should the nurse do first?" The students were polled on a total of 6 nursing actions based on the safety and infection control components of taking vital signs. The entire scenario took approximately 20 minutes to complete, with students having 20 seconds to answer a single question for each nursing action. After the scenario was completed, the students were debriefed and reviewed the outcomes of their decisions. The debriefing took approximately 20 minutes.


Lessons Learned

One limitation of LICS was related to technology; being able to convey the next action to the nurse in the simulation room was difficult. The simulation took place down the hallway, and the instructor used a cell phone to tell the nurse what action the students chose next. Communication between the classroom and the simulation room slowed the scenario, directly affecting timing as well as decreasing realism. Another limitation was the students' inability to realize the consequences of their individual decisions if they were different from those of the group decision.


LICS could easily be performed remotely with students being livestreamed into the simulation room with Kahoot quizzing to be used for decision making. This delivery method would solve the problem of communication between the classroom and the simulation room since the instructor could receive the student's decision for the next nursing action via computer and then speak directly to the actors. This would result in fewer delays and make the scenario unfold seamlessly.


The large class debriefing session was effective; however, dividing students into smaller groups for debriefing before coming back as a larger group may be a more effective way to engage all students. If the activity were delivered completely online, the students could be sent into virtual breakout rooms for small group debriefing and then brought back to the larger group to report on what was discussed. Having a graduate or teaching assistant record comments during in-class or online debriefing would add to the accuracy of qualitative data.



LICS can be performed in a classroom setting or online and with a large number of students, in less time than traditional simulation. This innovative strategy provides an alternative to traditional teaching methods and engages students in their learning. This, in turn, allows students to apply abstract nursing concepts, utilize critical thinking skills, and immediately observe the outcomes of their clinical decision-making.




1. Benner P, Sutphen M, Leonard V, Day L. Educating Nurses: A Call for Radical Transformation. Jossey-Bass; 2010. [Context Link]


2. Moyer SM. Large group simulation: using combined teaching strategies to connect classroom and clinical learning. Teach Learn Nurs. 2016;11(2):67-73. doi:10.1016/j.teln.2016.01.002 [Context Link]