|Year : 2018 | Volume
| Issue : 2 | Page : 60-67
Translating the importance of simulation to practice: Strengthening learning outcomes
Farhan Alshammari1, Eddieson Pasay-an1, Maria Charito Laarni Indonto1, Ferdinand Gonzales2
1 Department of Medical-Surgical, Pediatric, College of Nursing, University of Hail, Hail, Saudi Arabia
2 Department of Community Nursing, Pediatric, College of Nursing, University of Hail, Hail, Saudi Arabia
|Date of Web Publication||2-Apr-2018|
Dr. Eddieson Pasay-an
College of Nursing, University of Hail, Hail
Background: Evidence against the positive outcomes of simulation exists, but greater evidence for its effectiveness as an educational approach is recorded.
Materials and Methods: A quantitative cross-sectional design was employed using a total enumeration from the 2nd year to 4th year nursing students. The respondents were the 2nd to 4th year level Bachelor of Science in Nursing students enrolled during the school year 2016–2017 in the College of Nursing at the University of Hail, Kingdom of Saudi Arabia. Descriptive statistics were used to determine the level of importance and practices of simulation. Meanwhile, the F-test (one-way ANOVA) was used to examine the differences on year level, course, and the age.
Results: The level of simulation practice of the students is generally “often practice,” and the importance of simulation is considered “important.” The active learning level of practice is 3.89 while the level of importance is 4.09; collaboration is 3.75 for the level of practice and 3.93 for the level of importance; for the diverse ways of learning 4.13 and 4.14 for the level of importance. Interestingly, as to “high expectations,” the mean result is 4.42 for the level of practices and for the level of importance the mean result is 3.91. According to year level, age and courses, no significant difference in both the level of importance and in the practice of simulation were recorded, as indicated by the P values that were greater than 0.05 level of significance.
Conclusion: Specific variables can greatly influence the practice and simulation technique.
Keywords: Importance, learning outcomes, practice, simulation
|How to cite this article:|
Alshammari F, Pasay-an E, Laarni Indonto MC, Gonzales F. Translating the importance of simulation to practice: Strengthening learning outcomes. J Health Spec 2018;6:60-7
|How to cite this URL:|
Alshammari F, Pasay-an E, Laarni Indonto MC, Gonzales F. Translating the importance of simulation to practice: Strengthening learning outcomes. J Health Spec [serial online] 2018 [cited 2020 Apr 5];6:60-7. Available from: http://www.thejhs.org/text.asp?2018/6/2/60/229027
| Introduction|| |
To advance the education of students to meet the desired outcomes and ensure patient safety in the clinical setting, an educational approach like simulation is to be considered. Simulation transforms declarative to functional knowledge, which prepares learners to play their roles as competent and competitive healthcare providers. To make sense, the facilitator needs to involve the learners in achieving the learning objectives and also help them understand the practice of simulation, thereby meeting the learning outcomes. From an operational standpoint, simulation before engagement to actual or genuine setup gives learners more confidence and clears any vague expectations. These experiences provide learners with the opportunity to correct their errors during their simulation, thereby preventing similar errors in actual setting  and simultaneously learning to link theories to practice.
In the practice of simulation, facilitators help learners recognize the importance of simulation. As such, it helps in increasing their level of confidence by providing them classroom activities similar to hospital scenarios, although some researchers , contend that learning in a simulated setting gives learners a safe and supportive environment. It improves the way they think and eventually enhances their clinical skills. A good number of researches showed that learners who have experienced simulation displayed an excellent outlook towards learning and developed their competence as well as their confidence., Studies have likewise demonstrated that learners benefitted from simulation as they manage their various learning needs, build teamwork, and develop their communication skills., Jeffries  added that elements of simulation include the following: a clear goal, pre-simulation conference between the teacher and students, realistic time allocation, and clear instructions before implementation. However, researchers such as Sanford, Robertson, and Schoening et al. claimed that there are inconsistencies in some published literature relative to the good results of simulation practice. Blum and Parcells  stated that simulation in nursing as an educational approach other than learning strategies does not support safety competencies. Schiavenato  claimed that simulation is inadequate and restrictive. Hayden et al. posited that simulations enhance the ability but do not affect knowledge acquisition in one way or another.
Due to these contradicting claims relative to the use of simulation, the need to conduct more research on the practice of simulation is of great importance. Thus, this research is significant in demystifying the claims regarding importance and practice of simulation in the classroom. This way it helps both facilitators and learners to prove claims that simulation strategy is significant in meeting desired learning outcomes. This research endeavour aimed to determine the practice of simulation in the Baccalaureate degree in Nursing at the University of Hail, Kingdom of Saudi Arabia. Specifically, it purported to know the level of importance of simulation and the practice of simulation along four aspects: active learning, collaboration, diverse ways of learning, and high expectation. Moreover, it aimed to determine the relationship between variables such as respondent's year level, course, and age with the importance and practice of simulation.
This research is primarily guided by the concept of constructivism,, which posits that learners are responsible for their learning, that their present interactions with their teachers and peers help build and shape their knowledge. These learners may experience frustrations as they associate previously-learned abstract concepts with new concepts but through simulations such as active learning activities, collaboration, diverse ways towards learning and high expectation to which teachers facilitate, these learners eventually achieve desired learning outcomes in a safe environment.
| Materials and Methods|| |
The researchers employed a quantitative cross-sectional design to properly represent the phenomenon of simulation - its practice and importance in the learning process. In this way, it can be measured and objectively analyzed for further intellectual pursuits.
Locale and population
The respondents of the study were 2nd to 4th year level Bachelor of Science in Nursing students enrolled during the school year 2016 – 2017 in the College of Nursing at the University of Hail, Kingdom of Saudi Arabia. The said students were enrolled in courses that employed simulation in their classrooms. Total enumerations were used to ensure representation of the samples.
The researchers utilized the simulation survey instrument adapted from the work of Chickering and Gamson, which was published and widely used by the National League for Nursing (NLN). The survey instrument consists of 16 questions, categorized into four sections: active learning, collaboration, diverse ways towards learning, and high expectation. The reliability of the instrument tested using Cronbach's alpha were noted as follows: the presence of practices at 0.86 and importance of specific practices at 0.91 showing a high level of reliability.
Data gathering procedure
On approval of the Ethics Review Board of the University of Hail, the researchers then proceeded in the data gathering. A cover letter was provided to the participants, which included the brief description of the study, the significance of the study, rights of the participants such as the right to withdraw, anonymity, and confidentiality. Data gathering was performed from November 2016 to January 2017.
Inclusion and exclusion criteria
For this research to be ethically sound, inclusion and exclusion criteria were observed by the researchers. For the inclusion criteria, the respondents (1) should have experienced simulation in their courses; (2) should be willing to participate and (3) should be 2nd, 3rd or 4th year nursing students. For the exclusion criterion, the respondents have no simulation in their courses.
All data were processed through SPSS Version 21 (IBM Software Group, Chicago, IL, USA). The demographic profile was treated using frequency count and percentage. Weighted mean was used to determine the level of importance and respondents' extent of practices and simulation strategy. To examine the level of simulation importance and its extent of practice and if it differed according to year level, course and age, the F-test (one-way ANOVA) was used.
| Results|| |
Participants' demographic profile
The majority (68%) of the Bachelor of Science in Nursing respondents are of the 3rd year level. The remaining 32% of the respondents are from the 2nd year (24%) to 4th year (8%) levels. The paediatric course (38%) and Advance Adult Care Nursing (35%) are the two top courses where respondents are enrolled, and the least number enrolled in Critical Care Nursing. Regarding age, most of the respondents were 21 years of age; few within the age range 18–19 and 25-26 years. [Table 1] shows the demographic profile of the respondents.
Level of practices and importance of simulation to the nursing students
[Table 2] shows the level of practice and importance of simulation for the nursing students along “active learning,” “collaboration,” “diverse ways toward learning,” and “high expectations.” As to “active learning”, the mean results are as follows: 3.89 (level of practices), 4.09 (level of importance), collaboration mean result 3.75 (level of practices) and 3.93 (level of importance). On the “diverse ways of learning” the mean resulted to 4.13 (level of practices), and 4.14 (level of importance). Interestingly, as to “high expectations”, the mean result is 4.42 for the level of practices and 3.91 for the level of importance.
|Table 2: The level of practices and importance of simulation of the nursing students|
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Differences on the practice of simulation among students grouped according to year, age and course
As revealed in [Table 3], when grouped according to year level, age, and course, the “active learning” has varied results on the specific items. As to year level, specific item 3 which states “I had the opportunity to put more thought into my comments during the debriefing session” has a P = 0.022;, item 4 which states, “There were enough opportunities in the simulation to find out if I clearly understand the material” with P = 0.00; item 5 which states “I learned from the comments made by the teacher before, during, or after the simulation” with P = 0.036; item 9 which states “The instructor was able to respond to the individual needs of learners during the simulation” with P = 0.003; Item 10 which states “Using simulation activities made my learning time more productive” with P = 0.002. The items above showed significant results having a lower P value against the 0.05 level of significance. The age, on the other hand, revealed no significant result has a higher P value from the set value of 0.05 level of significance. Further, all items in the “course” revealed significant results with P < 0.05 level of significance. Under “collaboration,” the year, age, and course revealed no significant results with P values higher the 0.05 level of significance, except item 12 under the “course,” which revealed significant result with lower P = 0.044 against the 0.05 level of significance. On the aspect of “diverse ways of learning”, both year level and age resulted in nonsignificant, while course proved to be significant having P = 0.001 and 0.003 for items 13 and 14, respectively. Finally, the “high expectations” resulted in non-significant, specifically year level, age and item 16 under the “course,” but significant to item 15 which had P = 0.001.
|Table 3: Differences on the practice of simulation among students grouped according to year, age and course|
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Differences on the level of importance of simulation across year levels, age, and courses
[Table 4] shows the differences on the level of importance of simulation along four aspects: “active learning,” “collaboration,” “diverse ways towards learning,” and “high expectation.” Using the 5% level of significance, there exists a significant difference as to some items on the level of importance of simulation when grouped to year level, age, and course along “active learning.” Item 2 which states “I actively participated in the debriefing session after the simulation” had P = 0.019. With regard to year level; item 4 which states, “There were enough opportunities in the simulation to find out if I clearly understand the material,” had a P value = 0.001 as to year level, and P = 0.002 along course; item 5 states “I learned from the comments made by the teacher before, during, or after the simulation,” with P = 0.023 on year level and P = 0.001 along the course; item 6 states, “I received cues during the simulation in a timely manner” with P = 0.001 on year level; item 8 states, “I had the opportunity to discuss ideas and concepts taught in the simulation with my instructor” with P = 0.001 along year level and P = 0.002 along the course; item 9 states, “The instructor was able to respond to the individual needs of learners during the simulation” with P = 0.001 in the year level, and P = 0.001 along the course; and lastly, item 10 states “Using simulation activities made my learning time more productive” with P = 0.001 along year level.
|Table 4: Differences on the level of importance of simulation across year level, age, and courses|
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As to “collaboration,” the year level and age are not significant with their P values, which is higher than 0.05; however, the “course” resulted to significant difference having lesser P = 0.399 for item 11 which states, “I had the chance to work with my peers during the simulation,” and item 12 which states, “During the simulation, my peers and I had to work on the clinical situation together” with a P = 0.000.
For the “diverse ways of learning” item 13 which states, “The simulation offered a variety of ways in which to learn the material.” with P = 0.045 against the set level of significance of. 05 resulted in the significant difference as to year level. Item 14 which states, “This simulation offered a variety ways of assessing my learning” having a lesser P = 0.044 than 0.05 implies significant difference
Finally, under “high expectations,” both year level and age resulted to no significant difference; however, the “course” has lesser P = 0.008 for item 15 which states, ” The objective for the simulation experience were clear and easy to understand”, and 0.000 for item 16 which states, “My instructor communicated the goals and expectations to accomplish during the simulation” both of which resulted to significant difference using the 5% level of significance.
| Discussion|| |
The high level of simulation practice regarding active learning revealed in this study duplicates the findings of the study of Lalley and Miller. In their study, students only retain 10% of what they hear while they retain up to 75% of the material that they have an opportunity to practice. Yuan et al. in a related study asserted that dynamic learning improves the learners to keep up tracking the learning procedure and fosters a high sense of responsibility, hence ensuring patient safety. Henderson and Trotta  also recommended that in promoting student success, educators need to make sure that there is no disconnect between concepts covered in class, content on the test and no disconnect with items.
The functional outcomes in the level of practices and importance of simulation of the nursing students under “collaboration” can mean to say that the learners recognized the activity in a way that let them achieve the essential learnings. As such, these learnings should be applied in a simulated setting that allows a free opportunity for them to be demonstrated interactively.
The research finding is supported by the study of Tschannen et al., which showed that any simulation cases that demand communication contributes an immense improvement in collaboration and eventually patient outcomes. The study of Wang et al., further supports this study where learners responded emphatically to their simulated inter-professional encounters. The learners themselves had a significant transformation toward cooperation and joint effort, proficient character, and understanding. As such, the inter-professional based simulation can then be practiced by the future health professional to comprehensively upgrade the adequacy of preparing them toward an interprofessional way of dealing with patient care. In addition, Yuan et al., conducted a study about learners' perspectives on the existence and significance of learners' application in the high-fidelity simulation. The investigation uncovered that working with others frequently builds inclusion in adapting to the interim thought sharing and that reacting to others' responses can enhance cogitation and extend understanding.
About diverse ways of learning, the nursing respondents acknowledged that simulation offers regulation of circumstances that advance critical thinking. Hence, this permits excellence in patient care, gives quick input, and enables learners to incorporate learning and actual involvement. This finding matches the study of Morgan-Eason, which talks about providing students with hands-on patient experiences that are expected to be encountered in the actual scenario in the simulation room. The simulation facility gives case situations in which learners need to effectively speak with the patient dummies. As such, they are tested to precisely evaluate and treat the patient in like manner and urges the learners to think and solve problems critically. However, this research contradicts previous assertions of Yuan et al. In Yuan et al.'s  study, it exhibited that more than half (69.4%) of the nursing respondents claimed that they had enough chances to see whether they plainly comprehend the materials. It recommends that learners should be urged to conceptualize thoughts on circumstances and issues and investigate critically the circumstances.
Along high expectations, it can be noted that the nursing respondents understood the aims of simulation to which learners need to understand what the facilitators are trying to communicate. This includes the goals and the expected outcomes that deem to be important in their learnings. These findings were discussed in Yuan et al.'s  study, which reveals that the objectives for the simulation experience should be understood by the learners. The respondents considered that learning from the tutor's comments was important. Moreover, this research finding is consistent with the study of Little  in which the students' responses varied from “strongly disagree” to “agree” when they were asked to give their response to the statement, “The simulation materials used in this simulation were motivating and helped me to learn.”
Level of simulation practice as observed and rated by the respondents grouped or categorized according to year level, age, and course
The significant difference in the level of simulation practice under active learning as perceived by the respondents as to year level implies a significant variable that accounts for the variation in the respondents' ratings for certain items in the simulation survey questionnaire. Moreover, the nonsignificant difference in the levels assigned by the respondents grouped according to age implies that age is not a significant factor that accounts for any variation in the respondents' level of simulation practice. On the other hand, the significant difference in the level of simulation practice in almost all the items of the survey questionnaire along “active learning,” “collaboration,” “diverse ways of learning” and “high expectation” means a higher sense of student participation in the simulation. Indeed, such finding replicates the findings of Rizzolo and Jeffries, Luebbert and Popkess. In all three studies, students were noted to have a greater sense of involvement in diverse ways of learning, higher expectations in the simulation performance and greater conviction that collaboration was part of their simulation. Luebbert and Popkess  revealed that group of students who were actively engaged in simulation scored higher in the test along active learning, collaboration and diverse ways of knowing subscales. Results suggest that students believe that the knowledge from the simulation was appropriate, directive and efficient. With the teacher's recognition of the need for teacher support during the simulation activities, learners were provided with greater support even in their development of independent problem-solving skills. Similarly, learners were provided constructive feedback for self-analysis. All these convince learners that the practice of simulation as a learning strategy is essential.
Differences on the level of importance of simulation along the four aspects: “active learning,” “collaboration,” “diverse ways of learning,” and “high expectations”
The differences in the level of importance of simulation could be attributed to the nature of the courses represented: Basic Adult Care, Critical Care Nursing, Advance Adult Care Nursing, Maternity and Paediatrics. This implies the need to vary simulation depending on the need of the students enrolled in such courses. Activities for simulation should be matched with future tasks or jobs. The lack of significant difference in the respondents' views on the importance and practice of simulation along certain areas reveal shared views on certain matters. These views include the value of time management facilitated by simulation, the uncountable ways of learning material, the variety of ways in assessing learning, open lines of communication between a teacher and a student to discuss learning objectives, constructive feedback and its like. These findings are supported by the study of Richardson et al. Findings from Richardson's study demonstrated that learners give the highest rating to the customary way of education, and rated simulation and didactic learning as the second (Learners' Expectation/High Expectations). Having achieved a greater sense of confidence of the learners from the middle until to the end of the programme, they reported stability of satisfaction. It has been reported that while they advanced through the programme, learners acquired an excellent perception about collaboration; have higher expectations of the programme, facilitators, active learning; and diverse ways toward learning.
The research of Souza et al., indicates that students experienced diverse experiences. It improved the probability of taking part in cooperation and the chances for learning with an expanded perspective between professional and evidence-based learning. These learners revealed a determination to accomplish scholarly engagement and complex thinking with a variety of experiences. Learners' contribution to various encounters advanced their development in engagement, inspiration, dynamic and thinking in a complex way. Furthermore, the students underwent involvement in active learning. Expanded dynamic learning was related to a more prominent capacity to think independently. Indeed, it is a more remarkable ability to discover and orchestrate data, with enthusiasm to learn on their own. The learner-facilitator interaction gives learners a more profound use of case scenario, conceptual map, and criticism to help their learning. Facilitators do not only serve as a guide to the learners who are already adept in the clinical set-up but also intensify their needs to take part in the clinical environment. All of these point to one thing: that simulation results to positive learning outcomes. This finding is also corroborated by the study of Bangert, which conveys that 97% of learners who specified the course was intended to enable them to assume accountability for their own learning. The outcomes of the inquiries relating to high expectations propose that most learners felt that models utilized to show problem-solving conveyed desires for weekly group problems. It is recommended, therefore, that the utilization of good cases and models unmistakably conveyed facilitators' desires, as well as furnished learners with challenging obligations that can be effectively finished.
Overall, simulation was considered by the nursing students as an important strategy in facilitating active learning; fostering collaboration, providing a variety of learning experiences and communicating learning goals and expectations; whereas, students considered the level of simulation practices very high along the given areas.
| Conclusion|| |
The Bachelor of Science in Nursing students at the University of Hail profoundly recognized the importance of simulation as a learning strategy that produced the desired learning outcomes such as competence and competitiveness in the clinical setting, collaborative skills, positive views on feedback, increased the level of confidence and expectations. Under each of these items, the respondents demonstrated inclinations to various ways of learning and learning assessment, perceived clarity in the communication of goals, objectives and expectations. These variations to a greater or lesser degree are affected or influenced by the demographic profile of the respondents such as year level, age and courses taken. Given the conclusion above, the general characteristics of the dominant group of student population may be considered, as well as their specific traits, which could significantly influence their simulation practice. Moreover, the natural characteristics of students under each age group and the requirements for each course should be considered in the selection of activities for simulation.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Jeffries PR, Clochesy JM. Clinical simulations: An experiential student-centredpedagogical approach. In: Billings DM, Halstead JA, editors. Teaching in Nursing: A Guide for Faculty. Vol. 4. St. Louis, MO: Saunders Elsevier; 2012. p. 52-68.
Ricketts B. The role of simulation for learning within pre-registration nursing education – A literature review. Nurse Educ Today 2011;31:650-4.
Medley CF, Horne C. Using simulation technology for undergraduate nursing education. J Nurs Educ 2005;44:31-4.
Valler-Jones T, Meechan R, Jones H. Simulated practice – A panacea for health education? Br J Nurs 2011;20:628-31.
Shapiro MJ, Morey JC, Small SD, Langford V, Kaylor CJ, Jagminas L, et al.
Simulation based teamwork training for emergency department staff: Does it improve clinical team performance when added to an existing didactic teamwork curriculum? Qual Saf Health Care 2004;13:417-21.
Hope A, Garside J, Prescott S. Rethinking theory and practice: Pre-registration student nurses experiences of simulation teaching and learning in the acquisition of clinical skills in preparation for practice. Nurse Educ Today 2011;31:711-5.
Dearmon V, Graves RJ, Hayden S, Mulekar MS, Lawrence SM, Jones L, et al.
Effectiveness of simulation-based orientation of baccalaureate nursing students preparing for their first clinical experience. J Nurs Educ 2013;52:29-38.
Jeffries PR. A framework for designing, implementing, and evaluating simulations used as teaching strategies in nursing. Nurs Educ Perspect 2005;26:96-103.
Robertson B. An obstetric simulation experience in an undergraduate nursing curriculum. Nurse Educ 2006;31:74-8.
Schoening AM, Sittner BJ, Todd MJ. Simulated clinical experience: Nursing students' perceptions and the educators' role. Nurse Educ 2006;31:253-8.
Blum CA, Parcells DA. Relationship between high-fidelity simulation and patient safety in prelicensure nursing education: A comprehensive review. J Nurs Educ 2012;51:429-35.
Schiavenato M. Reevaluating simulation in nursing education: Beyond the human patient simulator. J Nurs Educ 2009;48:388-94.
Hayden JK, Smiley RA, Maryann A, Suzan KE, Pamela JR. “The NCSBN National Simulation Study: A Longitudinal, Randomized, Controlled Study Replacing Clinical Hours with Simulation in Prelicensure Nursing Education”. J Nurs Regul 2014;5:4-41.
Dreifuerst KT. The essentials of debriefing in simulation learning: A concept analysis. Nurs Educ Perspect 2009;30:109-14.
Neill M, Wotton K. High-fidelity simulation debriefing in nursing education: Aliterature review. Clin Simul Nurs 2011;7:161-8.
Lalley J, Miller R. The learning pyramid: Does it point teachers in the right direction? Educ 2007;128:1.
Yuan HB, Williams BA, Man CY. Nursing students' clinical judgment in high-fidelity simulation based learning: A quasi-experimental study. J Nurs Educ Pract 2014;4:5.
Henderson C, Trotta D. Infusing simulation in classroom teaching. J Res Pract Coll Teach 2016;1:1.
Tschannen D, McClish D, Aebersold M, Rohde J. Improving nurse and physician communication through a nursing crew resource management (NCRM) intervention. J Nurs Care Qual 2015;30:7-11.
Wang R, Shi N, Bai J, Zheng Y, Zhao Y. Implementation and evaluation of an interprofessional simulation-based education program for undergraduate nursing students in operating room nursing education: A randomized controlled trial. BMC Med Educ 2015;15:115.
Morgan-Eason A. Enhancing communication skill in diverse learners. Acad Exch Q 2012;16:2-68.
Little GN. The Effect of a Simulation Experience on Student Perception of Self Confidence. Nursing Theses and Capstone Projects. Paper 68. Gardner-Webb University, Boiling Springs, North Carolina, USA; 2013.
Rizzolo MA, Jeffries MH. Designing and implementing models for the innovative use of simulation to teach nursing care of ill adults and children: A national, multi-site, multi-method study. Natl League Nurs 2006;7:261-2.
Luebbert R, Popkess A. The influence of teaching method on performance of suicide assessment in baccalaureate nursing students. J Am Psychiatr Nurses Assoc 2015;21:126-33.
Richardson H, Goldsamt LA, Simmons J, Gilmartin M, Jeffries PR. Increasing faculty capacity: Findings from an evaluation of simulation clinical teaching. Nurs Educ Perspect 2014;35:308-14.
Souza MS, Venkatesaperumal R, Radhakrishnan J, Balachandran S. Engagement in clinical learning environment among nursing students: Role of nurse educators. Open J Nurs 2013;01:25-32.
Bangert AW. The seven principles of good practice: A framework for evaluating on-line teaching. Internet High Educ 2004;3:217-32.
[Table 1], [Table 2], [Table 3], [Table 4]