Simulation for Nursing Students

Introduction
The PICO question for this study is: “In training nursing students how does using simulation compared to traditional classroom instruction affect their knowledge, skills and confidence within 4 months?” The literature review conducted to obtain relevant articles for this question focused on databases such as EBSCOHost and Google Scholar. In total 7 articles were retrieved and 5 selected for use. Search terms and keywords used to obtain the articles were: “simulation,” “nursing education,” “high-fidelity simulation training,” “instruction effectiveness,” and “simulation vs. traditional classroom.” The articles selected were:
· Briscoe, Mackay and Harding’s (2017) “Does Simulation Add Value to Clinical Practice?: Undergraduate Student Nurses' Perspective”
· Kapucu’s (2017) “The Effects of Using Simulation in Nursing Education: A Thorax Trauma Case Scenario”
· Afrasiabifar and Asadolah’s (2019) “Effectiveness of Shifting Traditional Lecture to Interactive Lecture to Teach Nursing Students”
· Unver et al.’s (2018) “Integrating Simulation Based Learning into Nursing Education Programs: Hybrid Simulation”
· Fernandez-Ayuso et al.’s (2018) “The Modification of Vital Signs According to Nursing Students’ Experiences Undergoing Cardiopulmonary Resuscitation Training via High-Fidelity Simulation: Quasi-Experimental Study”
This paper will provide a synthesis of the literature collected for this project.
Literature Synthesis
The study by Briscoe et al. (2017) conducted a Level VI study using the qualitative descriptive approach to obtain data from a focus group consisting of 10 nursing students. The nursing students discussed and gave their opinion on the role that simulation plays in preparing a nursing student for the real world of nursing, and the participants all felt that simulation exercises were valuable methods of learning. One of the problems that the researchers found, however, was that nursing students were generally unaware of or uninterested in the learning outcomes of simulation exercises. They were more interested in simply have the experience that simulation offered. Thus, even though prior research had noted that objectives are what help to guide the learning process, objectives had not played a significant part in the simulation experience for these nurses. The implications of this study are that it helps to show that nursing students welcome simulation as a way to gain experience, which is good for the EBP; however, what is bad for the EBP is that the study shows that simulation learning disconnected from awareness of learning objectives can prevent the maximum or desired effect of the educative process from being attained. This information is helpful to know for this EBP so that when the project is conducted and the PICO tested, the participants can be evaluated to see whether they are aware of the learning objectives associated with the simulation.
There were no evident factors in the article that might be detrimental to the study’s reliability or validity. The method was clearly described and the participants’ backgrounds were sufficiently explained. The focus group measured what the study aimed to measure and as the method was sufficiently described it would be possible to duplicate it in order to see if a similar set of findings was obtained from a similar focus group. Potential limitations of the study were that all the nurses came from one nursing school, which means the findings might reflect more on that one school’s methods of teaching—i.e., not connecting the learning objectives to simulation—than on the whole of the nursing school field in general (so possibly a reliability issue). A second limitation was the qualitative nature of the study and the fact that all descriptions were subjective and self-reported. No confounding variables were identified.
Kapucu (2017) conducted a similar Level VI qualitative study, though in this one the data was collected not by focus group but by the interview method. Seven nursing students participated and their views on the effectiveness of a high-quality hybrid simulation exercise were obtained. The strengths of this study were that the researcher was able to control the simulation environment and interview students afterwards. The implications for the EBP are that it showed that the students generally felt more confident having had the experience of putting their skills to the test in a realistic setting. The only bad implication is that some of the participants were made nervous by the simulation environment and were conscious of the limited amount of time they had, which gave them anxiety. Another negative was, as one student pointed out, the simulation was not entirely realistic because the patient was not human but a dummy. This shows that the simulation used for the EBP should not be hybrid—i.e., should not use mannequins if possible.
Factors that might relate to reliability or validity would be the method used to analyze data. In this study, the method used to analyze the interview transcriptions was not fully explained, so validity and reliability factors could be an issue here—particularly with respect to the fact that all participants were, once again, all from one school. This is a limitation similar to that in the study by Briscoe et al. (2017). Again, no confounding variables were presented in this study.
Afrasiabifar and Asadolah (2019) conducted a Level III quasi-experimental study in which 29 students participated in a simulation-based learning course of 18 sessions. Their scores and satisfaction levels were taken and compared to students who took traditional learning courses in nursing without simulation. The study found that the students who took the simulation-based courses felt like they had engaged in more active learning than the students who took the traditional course, and they scored higher as well. The implications for this EBP are that students who engage in simulation should be better well placed for handling real world nursing issues after four months than students who do not receive simulation training.
The strengths of the study consisted of a well-described methodology and a higher level research than the previous two studies. The educational benefits identified by the researchers included greater understanding of taught materials, immediate feedback, and greater motivation to learn as learning would be put on trial. All of these help to show why simulation could be helpful in boosting nursing student development. The implications for the EBP are thus all positive. However, the study also had several limitations, including a small sample size, which could impact reliability. Additionally, validity could be impaired as some of the data was self-reported. There were no confounding variables identified.
The study by Unver was another like that by Kapucu (2017) and Afrasiabifar and Asadolah (2019). It was a Level III quasi-experimental study using hybrid simulation, with 39 students from Turkey. Unlike the study by Kapucu (2017), however, the students all felt that the simulation increased their ability to think critically, improved their ability to make effective decisions, boosted their self-confidence and made them feel like real nurses. While in the study by Kapucu (2017), some of the participants were confused and did not find the simulation effective, this study showed that overwhelmingly 95% of the student participants reported the effects of simulation to be positive. The strength of the study was the pre-tost, post-test design which allowed the researchers to gauge where the students were prior to the simulation and compare it to where they were cognitively speaking post-simulation. Overall, the study showed the hybrid simulation can facilitate learning in the nursing school environment. Thus there were no bad implications for this EBP in this study.
With respect to reliability, the study only used students from Turkey, so there may be some cultural issues in terms of the generalizeability of the findings. However, given the methodology involved, the study could be reliably duplicated. In terms of validity, the study did measure what it set out to measure, so there are no validity issues present in this study. Potential limitations include the small sample size. While it is a larger sample than some of the other studies, it is still not sufficiently large sample to provide any statistically significant evidence. Again, no confounding variables were identified in the study.
Fernandez-Ayuso et al. (2018) also conducted a Level III quasi-experimental study to assess the impact of high-fidelity simulation exercises on nurses learning about CPR, by taking blood pressure and measuring anxiety among nursing students from two groups—one with experience and one without. The study found that simulation exercises do have a psychological and physiological impact on nursing students. This has both good and bad implications for this EBP. First, it shows that the simulations can increase the stress and anxiety of students—however, the high stress and anxiety levels do decline during the simulation, indicating that students gradually overcome their fears and gain back control of their feelings as the simulation goes on and their training and skills kick in. Thus, the EBP will have to control for or at least take into consideration how emotions and stress can factor into perceptions about the simulation. Students who are very anxious going in and come out feeling calm and confident are more likely to view simulations favorably as compared to students who do not regain composure for whatever reason.
The reliability of this study is high, as the method is clearly explained. The validity of the study is high as well. The sample size for this study was the highest of all those reviewed, with 107 students participating in the study. The study measured what it set out to measure and thus the findings appear valid. The study could be duplicated without trouble and thus demonstrates reliability. Potential limitations of the study are the fact that the sample came from one class enrolled in a single course at a single university—so this is not a large-scale multi-site experiment. The level is only that of a Level III, and while higher than a Level VI, of course, it still lacks the randomized-controlled trial characteristics that mark higher level studies. No confounding variables were identified, though there could be some other reasons for high anxiety: the researchers excluded students who were on medication for anxiety—but other factors were not discussed. Overall, study results showed that the students from both groups were made nervous by the simulation but that in general nerves were able to be calmed as the simulations went on and students began to feel more confident about what they were doing.
Conclusion
These studies all come together to inform the EBP project by providing insights into how simulations can impact students (i.e., by elevating stress levels), how types of simulation can distress or benefit certain types of students (i.e., some students may be happy with hybrid simulations—others may not feel it is realistic enough and thus may question its benefit), and how important it is to connect learning objectives to the simulation so that students know why the simulation is being conducted in the first place. Though students may be aware that the simulation itself is helpful because it provides experience for the nursing student, if they do not have a sense of the learning objective they are not receiving the fullness of the lesson. Thus for this EBP it is important that these findings be incorporated into the manner in which the EBP project is constructed so that participants are aware of the learning objective, so that the simulation is realistic as possible, and so that stress levels are not made into seeming like they are higher than they should be. This EBP Project can proceed, however, under the helpful guidance of these studies, assured that a hypothesis of finding simulation to increase students’ confidence will not be rejected.

References
Afrasiabifar, A., & Asadolah, M. (2019). Effectiveness of shifting traditional lecture to
interactive lecture to teach nursing students. Investigación y Educación en Enfermería, 37(1), 9.
Briscoe, J., Mackay, B., & Harding, T. (2017). Does simulation add value to clinical
practice?: Undergraduate student nurses' perspective. Kai Tiaki Nursing Research, 8(1), 10.
Fernández-Ayuso, D., Fernández-Ayuso, R., Del-Campo-Cazallas, C., Pérez-Olmo, J. L.,
Matías-Pompa, B., Fernández-Carnero, J., & Calvo-Lobo, C. (2018). The Modification of Vital Signs According to Nursing Students’ Experiences Undergoing Cardiopulmonary Resuscitation Training via High-Fidelity Simulation: Quasi-Experimental Study. JMIR serious games, 6(3), e11061.
Kapucu, S. (2017). The Effects of Using Simulation in Nursing Education: A Thorax
Trauma Case Scenario. International Journal of Caring Sciences, 10(2), 1069.
Unver, V., Basak, T., Ayhan, H., Cinar, F. I., Iyigun, E., Tosun, N., ... & Köse, G. (2018).
Integrating simulation based learning into nursing education programs: Hybrid simulation. Technology and Health Care, (Preprint), 1-8.