1. Guimond, Mary Elizabeth "Betsy" MN, RN, WHNP-BC
  2. Salas, Eduardo PhD

Article Content

With the availability of highly sophisticated simulations and manikins that emulate a wide variety of physiological changes and disease states, nursing faculty members are challenged with how to best integrate simulation into curriculum. The literature from which simulation training began can further inform faculty.



Approximately every 10 years, the Annual Review of Psychology publishes a review article of the scientific literature focused on training. Common issues in the reviews are those of task needs analysis, pretraining issues, training design, evaluation, and transfer of knowledge.1-4 Adherence to the theories and principles presented in these reviews results in more effective use of learning development strategies and knowledge transfer.5 Translation of these findings to nursing education will likely provide more effective simulation training that can be transferred to the clinical setting. Two principles from the science of training can inform faculty members as they design and deliver simulation-based training (SBT) in nursing education. These principles have been successfully integrated into military and aviation training.


The Importance of a Task Analysis: Is It Really Plug and Play?

Simulation using patient simulators (PS) is a tool for learning. The use of simulation in a curriculum does not create learning on its own. The simulation experience must be carefully planned and designed to maximize its effectiveness.4


Recently, major manufacturers of manikins have marketed simulation scenarios for SBT. The prepackaged scenarios are designed to save time in developing scenarios and may improve the acceptance of SBT. Also, networks of PS users are developing shared resources to save time and reduce costs associated with developing scenarios. In both instances, the ready availability of scenarios and marketing campaigns for manikins may create an unforeseen problem. There is a danger of the technology driving the curriculum, rather than the reverse.


The training literature provides a method to avoid this pitfall. The first step to good training is an adequate task analysis. This analysis is a detailed examination of the knowledge, skills, and attitudes important to any given job or task. Task analysis results provide a detailed blueprint of the competencies that guide the development of learning outcomes and scenarios or the scenario selection process. Those who are developing scenarios can use this information to carefully design events or triggers to elicit the required knowledge, skills, and attitudes from the trainees. Using task analysis helps the faculty members to select or craft scenarios that are most appropriate to the needs of their learners.


Higher Fidelity Does Not Always Produce Better Simulation

Simulators are classified as high or low fidelity based on their technological features. Simulators at the highest end, with the capability to mimic intricate patient physiology, are referred to as high fidelity. Patient simulators having some feedback capability such as blood pressure and breath sounds but lacking cardiac monitor output and breathing motion are considered middle fidelity. Manikins that have no electronic feedback are generally referred to as static. Higher fidelity manikins are perceived as providing superior experiences.


Fidelity of the experience is influenced by a number of factors. Technology is only one of them, and it may not be the most important. An excessive focus on physical fidelity may even be a distraction.6 In aviation, researchers found that when training for cognitive tasks and procedures, high transfer can be achieved. Their research has demonstrated that there is no difference in learning outcomes between inexpensive low-fidelity training and more expensive high technological fidelity training.7 What should be considered is the "cuing potential" or the ability of a particular feature to initiate a response by the learner.6 The cuing necessary for the given task serves as the guide for selection of a PS for a particular task, not the level of technical fidelity. Medical researchers have found similar results. One large-scale study concluded that low-fidelity manikins produced highly fulfilled educational outcomes when used in a multiprofessional training.8


For nursing educators, this means that the tool should suit the task. A static manikin or task trainer may be effective, depending on how the scenario is designed and the task. Use of a highly sophisticated manikin for a beginning student probably is not efficient for many tasks. However, for more advanced students needing to recognize physiologic changes, the use of high-fidelity manikin enables the interpretation of cardiac rhythm strips, assessment of dynamic physiologic parameters, and maximal interactivity with others participating in the simulation.


Food for Thought

What the nursing literature is missing are strategies for systematic planning of SBT. A methodological approach to integrating SBT into the curriculum is successful because it creates an environment that supports learning, knowledge transfer, and evaluation of the training. Theoretical frameworks that consider critical issues for training are available and can be adopted for nursing education.9,10 The use of the task analysis can identify outcomes that are appropriate for the needs of a particular program and identify the best tool for a particular task or skill. If nursing educators combine a systematic plan based on the science of training with the recent work of nursing researchers, learners will achieve the maximum benefit from SBT.11,12 Use of an evidenced-based theoretical framework for SBT such as those found in the science of training is an important step in the process of evidence-based simulation integration into nursing education.




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