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1Use of Clinical Simulation in Medical and Health Care Education

Use of Simulation in Medical and Health Care Education

Michelle Pryce

Clemson University


Abstract

Simulation has been defined as “the technique of imitating the behavior of some situation or

process (whether economic military, mechanical, etcetera) by means of a suitably analogous

situation or apparatus, especially for the purpose of the study or personnel training” (Bradley,

2006, 254) and has long been used to augment learning of specialized skills in medical and

health care education. Simulation provides a safe environment in which to practice life-saving

skills while minimizing the risk to living patients. Early simulation used resuscitation models

which allowed for the practice of basic life support skills. As simulation education progressed,

more advanced models allowed for the practice of intubation, IV/IO (intravenous/intraosseous)

insertion, or arrhythmia management. Now, even more advanced models called Human Patient

Simulators (HPS) are available to educate future medical professionals. These high tech models

allow for real-time monitoring, make physiological changes based on the student’s actions, and

provide feedback of performance. These HPS models along with CDs pre-programmed with

patient scenarios allow students in health care related fields to practice and gain confidence prior

to interaction with real patients.


USE OF SIMULATION IN MEDICAL AND HEALTH CARE EDUCATION

In order to train new health care workers, clinical educators have relied on clinical

rotations in hospitals, clinics, and other patient care sites, and hands-on instruction, usually

provided in a clinical skills laboratory, to train new physicians, nurses, and other health care

workers. However, clinical rotations are exceedingly dependent on the needs of the patients seen

during theses rotations and the quantity of patients available on clinical rotations. Moreover the

“see one, do one, teach one” method of training skills is not the safest way to train new

physicians and health care workers. However, in recent times, educators have been concerned

with not only the need for patient safety, but also the need to provide safe opportunities to

practice high-tech patient monitoring in rapidly changing environments. In a recent edition of

Quality and Safety in Health Care, Rodriguez-Paz “wrote physicians-in-training may expose

patients to harm when trying to gain skills. He and his co-authors suggested a new training

paradigm that includes a medically simulated environment” (Trossman, 2010, 12). As

technology continues to evolve, more opportunities become available for health care students to

practice technical skills in safe environments. In recent times, educators have been concerned

with not only the need for patient safety, but also the need to provide safe opportunities to

practice high-tech patient monitoring in rapidly changing environments. Within the last few

years, health educators at all levels have been able to add various levels of clinical simulation

scenarios to the educational mix.

Clinical simulation has been defined as “the artificial representation of a phenomenon or

activity” (Larew, Lessans, Spunt, Foster, & Covington 2007, 17) which is “a constructed reality

[that] allows participants to experience a realistic situation without the real-world risk” (Larew et


al., 2007, 17). Today there are several types of simulators available for health care students.

Basic models range from heads on which to practice intubation, arms on which to practice IV

insertion and blood draws, and pelvises on which to practice doing vaginal exams. While

allowing the novice health care student a chance to practice a new skill, performing these skills

on these manikins is rarely a good imitation of the real thing. Slightly more advanced models

allow for auscultation of heart and lung sounds, while highly advanced models can imitate a

patient’s rapidly deteriorating condition if accurate medical care is not provide within a timely

manner. It is these high-fidelity human patient simulators that have health care educators excited

about bringing technology into the classroom allowing students to gain confidence in not only

their procedural abilities, but also their abilities to manage several events simultaneously as what

could conceivable occur in an intensive care unit or emergency or trauma unit. Another benefit

that arises from using human patient simulators to teach complicated and /or invasive procedures

includes learning how to manage errors that are a natural part of learning without having to

experience negative patient outcomes.

SimMan™ is one type of these high-fidelity human patient simulators being used in

medical, nursing, and other allied health schools for training. SimMan™ can be programmed to

have “realistic and individual responses to health care scenarios” (Childs & Sepples, 2006, 154).

Studies involving the use of SimMan™ are becoming more widely available as SimMan™

becomes more popular in university training laboratories and in university medical centers’

training laboratories. Simulation education provides a safe learning environment for students to

practice and refine their techniques for invasive procedures and hone patient management skills

that will need to be performed in critical, high stress, environments.


DISCUSSION

Simulation is not a new phenomenon in health care education. While different institutions and

different disciplines may incorporate it differently into their curriculum, the format and goals are

similar. Over the last twenty years, simulation has evolved from the exclusive use of partial task

trainers to CD-ROMs that allow for individual to progress through scenarios at their own pace to

high fidelity human patient simulators. However, in the last few years, simulation education has

experienced tremendous growth both in types of simulation experiences available and sites

where simulation is available. Simulation education has been incorporated into nearly every

aspect of medical and health care education from phlebotomy training to life and death situations

to newborn delivery and end of life care. It is used by students in medicine, phlebotomy,

nursing, physical, occupational, speech, and respiratory therapies. Simulation has been shown to

not only increase abilities and confidence levels in gaining the skills they need to succeed in their

chosen profession, but also to enhance their happiness in their program. A survey conducted in

2007 by the Higher Education Academy questioned why students did not return for their second

year of university education. The top three reasons for withdrawal were “poor quality of

teaching, a lack of formative feedback from teachers, and the programs did not meet students’

expectations” (Haidar, 2009, 23).

Clinical simulation has been demonstrated to address each of these issues. Several

studies have reported that students’ self-confidence increased as a direct result of being involved

in simulation education, their decision making has improved due to debriefing sessions held

immediately after clinical simulation experiences, and perception of faculty’s teaching ability has

improved as a result of working directly with faculty members in simulation experiences.


Health care will continue to evolve. As political and social pressure to increase patient

safety grows and political mandates to reduce errors in health care situations, educators will face

a greater challenge in helping their student acquire the skills needed to thrive in patient care

areas. Simulation education is a perfect solution to these challenges. An article in Medical

Education, by Paul Bradley written in 2006, acknowledges that “medical education is an

expensive undertaking; like other aspects of health care it demands attention to the cost

justification of the outcomes of the process; without such evidence, simulation, for example, is

unlikely to persuade those who manage the funding of the potential benefits. Without

commitment to evidence base, at best simulation will retain a peripheral place in education and

training; at worst the process will stagnate for the lack of forceful argument in its favor.” (260).

Is simulation technology worth the expense? Many people say that it is. The Agency for

Healthcare Research and Quality and the Institute of Medicine has embraced the use of

“simulated team-training activities as means of reducing medical errors and improving patient

safety” (Lighthall & Barr, 2007, 277). Similarly, insurance carriers are beginning to recognize

the “value of such training by reducing malpractice premiums for anesthesiologists at institutions

at which all active clinical staff have participated in a crisis management and team-management

course” (Lighthall & Barr, 2007, 278).

Simulation technology seems to be the answer to many questions. As more studies are

conducted and can show a direct correlation between reduced errors and the amount of time

spent using simulation education, simulation technology will continue expand as it becomes

easier to justify the cost associated with simulation learning. High fidelity patient simulators,

partial task trainers, virtual reality simulator, and skill specific CD-ROMs are excellent additions


to classroom instruction and clinical rotations in order to increase students’ ability to perform in

the healthcare setting after graduation.

Literature Review

Laerdal Corporation, a leading manufacturer of human patient simulation technology, and

the Nation League of Nursing has designed a multi-year, multi-site intended to explore, integrate

and evaluate simulation education into nursing education. Eight schools of nursing were chosen

to assist in evaluating the projects overall goals. In addition, each school was allowed to select

and evaluate an additional component of the project to further assess the usefulness and

assimilation of simulation technology into nursing education. This study was conducted at the

College of Nursing and Health Professions at the University of Southern Maine. The college

chose to study simulation development and implementation and measure student satisfaction as

an outcome.

Nursing, by nature, is a profession in which beginning nursing students must acquire

knowledge, translate that knowledge into critical thinking, develop not only technical skills but

also self-confidence in performing those skills, and finally transfer the entire knowledge base to

the clinical setting where nurses perform their duties in caring for patients. Most nursing

programs have access to a clinical skills laboratory which allows for practice of skills prior to

beginning clinical rotations. Technology has always assisted educators in explaining new and/or

difficult concepts. Older technology used photographs to visualize symptoms of a condition and

audio recording to hear abnormal breath sounds. Newer technology introduced manikins and

computer based simulations while the latest technological innovations use human patient

simulator models capable of providing real-time feedback based on the student’s selected or


performed actions. These HPS models can perform scenarios from the exceedingly simple to the

extraordinarily complex.

Using simulation in education can achieve better outcomes than lecture alone. Several

studies have shown that “students retain knowledge learned from a simulation for a longer period

of time compared to when the same skill is taught in the traditional way” (Childs & Sepples,

2006, 155). In addition, the acquisition of skills occurs at a faster rate, and learners are

consistently “more satisfied. Critical thinking is enhanced, which results in increased self-

confidence and improved problem solving skills” (Childs & Sepples, 2006, 155).

USM’s simulation consisted of four stations: two faculty dependent stations, and two

faculty independent stations. The dependent stations included a SimMan mega code scenario as

well as identifying rhythm strips with the assistance of faculty members. The independent

stations included identifying cardiac arrhythmias on a CD-ROM and faculty developed case

studies with answers provided during group discussion. There were a total of fifty-five students

divided into groups ranging in size from twelve to seventeen. These groups were subdivided into

groups of four to five students. Twenty five minutes were allotted for each station, and at the

completion of the station, the student have five minutes to complete an evaluation form.

Additionally, the students were required to assess the validity and reliability of the NLN/Laerdal

study. The national study used the Education Practice Scale for Simulation (EPSS) and the

Simulation Design Scale (SDS) to measure outcomes. The EPSS uses a five point scale to

measure how well four specific educational practices are available in the simulation and how

important each practice is to the learner. The four practices are as follows: active learning,

collaboration, diverse way of learning, and high expectations. The SDS is a twenty question


survey that asks the students to evaluate five design features of the simulation. The five design

features are as follows: objectives/information, support, problem solving, feedback, and fidelity.

Furthermore, the students were asked to complete a school specific questionnaire

measuring the student’s level of confidence, simulation usefulness, and feelings about simulation

as a teaching method. There were 13 items on this questionnaire, and finally, the students were

asked to rank the four stations in order of personal preferences.

Students ranked the simulation experience as “overwhelmingly positive” (Childs &

Sepples, 2006, 157). Some even commented that more was learned in this single activity than

any other learning activity in the entire nursing curriculum. They felt as if they learned the most

from the SimMan’s mock code scenario. The mock code was also rated most enjoyable and

most stressful. Student comments regarding the mock code scenario included “My anxiety was

the highest it has ever been” (Childs & Sepples, 2006, 157) and “Next time I see a code I will not

run the other way” (Childs & Sepples, 2006, 157). The independent stations were also rated

highly, however; students felt as if “they were pressed for time” in completing them.

Upon review of the scenario, it was discovered that even though 25 minutes had been

allotted for each scenario, it was not enough, nor was the 10 minute debriefing session after each

of the scenario enough time provide for the students to review what was learned and process

feelings associated with each scenario. The two faculty members and the one graduate research

assistant that was on hand to assist with the simulation experience was not enough as the mock

code required two faculty members by itself and others were needed to assist in other ways.

Four students per group seem to be the ideal arrangement for group simulation. In situations

where there were five students “one student felt left out and less involved than the others” and


“weaker student were able to step back and take a less active role” [than in smaller groups]

(Childs & Sepples, 2006, 157).

Overall, students and faculty at USM were impressed with the simulation experience.

Faculty members reported students learned psychomotor skills quicker and developed critical

thinking skills not normally seen until students enter clinical rotations. At USM, the simulation

experience met high expectations.

At the University of North Carolina-Charlotte (UNCC) simulation experiences were

integrated into the senior students Complex Illness and Disease Management class. Prior to the

integration of simulation, the class consisted of 15 weeks of eight hour clinical rotations in

various acute care setting. After the integration of simulation into the curriculum, three

simulation experiences are spaced evenly throughout the curriculum. Each scenario was

designed to take eight hours to complete and mirror the hospitalization experience from

admission to discharge. Goals of the simulation scenarios included “increasing student’s critical

thinking skills, promoting teamwork, developing collaboration between clinical and didactic

instructors, and fostering problem solving in a controlled environment (Smith, 2009, 128).

Additional goals included student’s “increased confidence and comfort in the clinical arena”

(Smith, 2009, 126). At UNCC, nursing faculty wrote three detailed scenarios using the content

covered in the senior-level class. Each scenario included details for “past medical history, social

history, diagnostic and lab values, client history, and medications” (Smith, 2009, 126).

Students were divided into eight groups each consisting of five or six students. Each

student was assigned a role—“primary nurse, assistant nurse, physician, nursing assistant,

documentation nurse, or other” (Smith, 2009, 127) prior to beginning the scenario. A limited

report is given to the students by the faculty member. Students had the option of asking for


more details prior to developing a plan of care. Other information available included history and

physical assessment, physician’s orders, progress notes, and lab data. The manikin “changes

constantly in response to the plan of care” (Smith, 2009, 127) developed by the nurse, and the

actions taken by the nurse. Students were instructed to change roles within their group, and at

the end of a scenario, the students were debriefed by faculty “with a series of questions” (Smith,

2009, 127). Additionally, students were asked to “reflect on their interventions and indicate

whether they would change the sequence of care, use different strategies to achieve better

outcomes, or something else” (Smith, 2009, 127).

Students and faculty ranked their clinical simulation experience as “overwhelming

successful” (Smith, 2009, 128). Student comments included that the “sim clinical has helped me

so much in actual clinical. I feel that it showed me my weaknesses, which allowed me to work

on certain skills. It also helped me to prioritize. After having sim clinical I felt a little more

confident with my next patient” (Smith, 2009, 128) while faculty comments included “I have

received positive feedback from all students related to simulation clinical. They feel it helps

them prepare better for clinical” (Smith, 2009, 128). In addition, faculty learned that “students

were intrigued by real-life, real time scenarios and began to correlate theoretical knowledge with

disease management in a controlled supportive, but representative environment (Smith, 2009,

128) Moreover, using simulation as a supplement to acute care clinical rotations promoted

confidence, comfort, and enhanced student’s decision making in the hospital, time management,

and problem solving skills.

Simulation education is also used in the training of critical care physicians. Medical

students face the same challenges as other health care students when learning to properly manage

patients in intensive care environments—they lack the experience necessary to be competent at


procedural skills, and cannot acquire them without causing undue risks to patients. “Expertise in

ICU procedural skills requires (a) an understanding of anatomy in 3 dimensions and of the effect

of injury or illness on a patient's anatomy, (b) familiarity with the hardware associated with a

procedure, and (c) the development of psychomotor skills for integration of these variables”

(Lighthall & Barr, 257). Partial-task trainers have been relied upon by physicians, nurses, and

respiratory therapists, and students of the disciplines to teach abnormal heart and lung sounds,

intubation skills, chest tube insertion, IV insertion, and arterial artery cannulation due to the fact

that it is not always possible to find a patient presenting with a particular abnormality or needing

a particular procedure done when senior staff are available to teach students. Using head, chest,

and arm models allow for procedural practice of these intensive care skills without patients

enduring a care delay or inexpensive students endangering patients.

These partial task trainers allow students to focus on the development of a skill without

worrying about the risk to patient or other physiologic symptoms of the patient. Now, educators

are wondering if adding physiologic condition to these manikins will improve student ICU

management skills as procedures cannot be separated from the physiologic condition of the

patient in the real world. One suggestion is adding virtual reality aspects to these task trainers.

Virtual reality (VR) simulators “are task trainers that integrate manual controls with a computer-

screen representation of a 3-dimensional anatomical space” (Lighthall & Barr, 261). This type of

technology has been applied to procedures involving internal anatomy, such as bronchoscopy.

These types of simulators incorporate “real-life phenomena such as patient movement, bleeding,

coughing, and view obstruction--which are nearly impossible to incorporate into plastic models

or cadaveric specimens” (Lighthall & Barr, 261).


Modern simulation education has its roots in training anesthesia residents “to manage

unstable patients in an operating-room setting” (Lighthall & Barr, 262). Beginning in the mid

1980’s, it was noticed that errors in anesthesia “were often preceded by multiple errors in

communication and planning, a lack of teamwork, a failure to ask for assistance, fixation on a

single concept or piece of information, and an overall failure to anticipate and recognize disasters

before they occur (Lighthall & Barr, 262). This realization contrasted to the prevailing wisdom

of the time that “medical mishaps occurred as the result of a single error of omission or [were]

committed by a single individual” (Lighthall & Barr, 262). To combat these errors, simulation

training was incorporated in to the anesthesia education curriculum. Now, with the availability

of human patient simulators, medical education increasingly relies on the technology available to

teach student how “multidisciplinary teams of critical-care providers to manage realistic

‘patients’ in an ICU-like environment and to gain firsthand experience managing these

‘patients’” (Lighthall & Barr, 264).

While many of critical care scenarios used in simulation education are developed

“outside the field of critical-care medicine, the general concentration of such efforts on

developing clinical scenarios of rare but catastrophic events, common types of physiologic

deterioration, and nontechnical aspects of critical-event management, such as communication

and teamwork, render much of this simulation work directly applicable to critical care training”

(Lighthall & Barr, 270). It has been noted that one of the best aspects of simulation training in

health care education has been the opportunity to “highlight the nontechnical or behavioral

aspects of medical crisis management” (Lighthall & Barr, 271) with the most important aspects

being the opportunity for debriefing immediately following the scenario and the opportunity to

repeat it as many times as necessary in order to achieve the desired result.


The principle challenge for organizations seeking to acquire technology is cost. As more

and more students are exposed to simulation training in their respective curricula, they tend to

expect such methods to be available at their places of employment. Unless these new health care

Practiconer happen to work at academic medical centers, this is not always the case. According

to Holtschneider in her article titled “Growing the emerging field of simulation education” in

the newsletter Briefings on Evidence-Based Staff Development, “even with the cost issue,

[simulation education is] extremely important to implement if institutions wish to remain

competitive” (2010, 4).

Hospitals are finding innovative ways to include simulation in their continuing education

curriculums. Two such solutions include hospital partnerships with local healthcare professional

schools and regional simulation centers to be use by employees of multiple facilities. Regional

simulation centers have the advantage of allowing facilities to pool resources in order to access

technology that otherwise would be beyond the financial reach of the individual facilities. In

addition, regional centers “can have the added benefit of bringing together diverse learners who

might not otherwise interact” (Holtschneider, 2010, 4) as these centers can duplicate multiple

environments such as pre hospital care, emergency department services, intensive care area,

surgical areas, and medical/surgical areas.

However, the question still remains about how to use low-cost simulation alternatives if

an institution is not able to invest in higher-cost technology. Since some of the high-fidelity

simulators (like SimMan™) can cost $50,000 or more, educators in these organizations can

begin a simulation program by using good-quality, but lower priced simulators. Task trainers are

generally low cost in comparison with patient simulators, and provide excellent simulation for


procedural skills. Almost all (artificial) body parts can be purchased to be used to simulate

procedures necessary for minimal level competence.

Alternatives also exist for human patient simulators for those facilities that just cannot

afford to purchase one (or more) to begin a simulation lab. For example, models exist that can

produce have heart and lung sounds as well as pulses and blood pressures. These models may

not be able to do everything that a HPS can do, but they can work well for smaller institutions or

institutions with a limited budget that are not good candidates for other options in obtaining

simulation equipment. An often forgotten method of simulation is role-playing. It is extremely

cost effective and skills such as communication, teamwork, and an “appreciation for the roles

that others on the team play” (Holtschneider, 2010, 5) can be learned. Another example of

increasing the cost effectiveness of simulation is to consider sharing of simulation scenarios. In

the last five years a national simulation alliance has been formed. One of the established goals

for the alliance is “fostering collaboration among different groups with a common interest in

simulation” (Holtschneider, 2010, 5). With these step being taken, simulation educators will

have the resources available to them to implement all types of simulation in to their organization

as finances allow.

Although simulation has been used by health care professionals for more than 20 years,

in the last five years it has gained considerable attention with the advent of human patient

simulators increased accessibility. Anesthesiologists have been “integrating simulation into

clinical training routinely since 1994” (Waxman, 2010, 29), and many nursing and other allied

health programs are beginning to integrate simulation education into their training programs as

well. Simulation education incorporates not only high tech method such as human patient

simulators and virtual reality simulation, but also low tech methods such as role-playing;


computer based simulations, and standardized patients. The challenge for educators becomes

how to choose which method(s) to incorporate into their programs to achieve their desired

educational outcomes.

As intensive care units and hospital in general become more dependent on technology,

the curriculum used to educate the future workers in these environments must change as well.

According to Waxman, “traditional teaching methods such as lecture, discussion, and laboratory

practice may no longer be effective in meeting the current demands of education and practice,

with the ultimate goal of meeting the employing organization’s patient safety goals” (2010, 30).

Simulation can offer tremendous benefits to an educational curriculum. It can allow practice in

areas where hospital clinical experiences are difficult to obtain, or in procedures that may present

unnecessary risk to patients. Due to the relative newness of simulation use in health care

education, educational programs have the unique opportunity to create their own simulation.

Currently, there are very few guidelines available for writing scenarios to be used in

simulation; however, there is a consensus that guidelines need to be established in order to write

scenarios, especially scenarios that will be used by more than one instructor or by several

institutions. At present, simulations are usually completed using “prewritten clinical scenarios

geared toward the experience lever of the learner” (Waxman, 2010, 30). Many institutions

choose to purchase these prewritten scenarios either because they lack the time or inclination to

write their own scenarios. Advantages of prewritten scenarios include scenarios that are

“validated, tested, and evidence based” (Waxman, 2010, 30). Using prewritten scenarios also

allows education faculty to concentrate on other areas instead of using time to develop

customized scenarios. However, disadvantages of using prewritten scenarios include inability to

share with other institutions, inability to customize based on curriculum or protocol, and cost.


Unfortunately, it may take several years before a database exists that allows sharing of scenarios

between institutions.

In addition to teaching specific skills, high fidelity simulators can be used to assess a

student’s level of clinical judgment. Several studies have shown that clinical experiences

provide varied levels of instruction and outcomes. In many programs student/faculty ratios are

too high to allow close supervision and faculty members do not have the opportunity “to observe

students making clinical judgments as they move through the learning process” (Dillard, et al.

2009, 100). Use of high fidelity simulation allows for a “comprehensive evaluation of the

development of clinical judgment as well as the recognition of gaps in their understanding of

clinical practice (Dillard, et al., 2009, 100). Although few published studies exist in nursing

education literature, literature concerning medical education reports that high fidelity simulation

education “improves student learning” (Dillard et al, 2009, 100). Students report that simulation

experiences have improved their confidence due to the realism of the simulation experiences and

the opportunity to practice repeatedly in safe environments (Dillard et al., 2009, 100).

Knowledge acquisition is one parameter that can be measured using simulation

education. A study conducted in 2001 by Nehring, Ellis, and Lashley measured knowledge

acquisition by using pretest, simulation experience, followed by a post test design. It found that

“students gained and retained significant cognitive knowledge from simulation practice” (Dillard

et al., 2009, 100). However, a follow up study conducted by Jefferies and Rizzolo found that

although knowledge levels increased after simulation experiences, there was no discernable

difference in knowledge acquisition base on the type of simulation used, whether was was pen

and paper, static manikin, or high fidelity simulation” (Dillard et al., 2009, 100). Similarly, an

additional study conducted by Comer in 2005 reported that “role-play techniques can serve as an


effective substitute for, and supplement to, simulation technology when teaching clinical nursing

skills” (357). Additionally students reported an “increased understanding of course material” and

faculty “observed a decrease failure rate on the corresponding course examination” (Comer,

2005, 357).

A 2009 study conducted by Dillard et al. used 68 students and faculty members from two

nursing schools to develop a method to evaluate clinical judgment skills using a human patient

simulator. Each student was given a patient with identical initial symptoms. Each student

encountered a patient was anxious, dyspneic, and lying flat in the bed with a nasal cannula lying

across its chest. Students were expected to notice, interpret, and respond to the patient’s

respiratory distress. Once the respiratory distress was corrected, other clues were given to the

students for various other symptoms.

Each simulation experience lasted approximately fifteen minutes. After the simulation,

the students were debriefed and completed a self-assessment questionnaire based on specific

criteria established by the faculty prior to conducting the simulations. A small subset of students

(n=25) followed their self-assessment questionnaire with written reflections based upon their

actions. These written reflections provided the students with the opportunity for the students “to

integrate their new understanding into their preexisting knowledge base” (Dillard et al., 2009,

101).

This simulation was created to measure “the ability of students to make sense of data and

in how to set priorities” (Dillard et al., 2009, 102). After this simulation experience most of the

students reported that they “got the concepts” (Dillard et al., 2009, 103). Faculty members

reported that could indentify “a student’s clinical judgment ability from the written work,


identify performance deficits and strengths, and use theses to modify the student’s future

learning needs” (Dillard et al., 2009, 103).

CONCLUSION

Clinical simulation is an education tool that permits the training of individuals through

the re-creation of some aspect of the real world application. Simulation education takes many

forms from the low tech, low cost method of role-playing to the high tech, high cost of human

patient simulators. While research into this rapidly evolving field continues, published studies

demonstrate that simulation education does improve learning and has more positive outcomes

than traditional methods of education. However, the literature does not report that one specific

type of simulation consistently obtains more positive outcomes than any other type of simulation.

High fidelity human patient simulators are the future of education, but if educational departments

cannot afford to outfit their entire department with these manikins, they should not rule out

incorporating other methods of simulation into their education department. For the best possible

outcomes, education departments should develop a curriculum that includes simulation education

prior to purchasing the latest and most expensive models available and upgrading as more

objective research becomes available.


REFERENCES

Bradley, P. (2006). The history of simulation in medical education and possible future

directions. Medical Education (40), 254-262.

Childs, J.C. & Sepples, S., (2006). Clinical Teaching by Simulation: Lessons Learned from a complex

patient care scenario. Nursing Education Perspectives, 27 (3) 154-58.

Comer, S.K., (2005). Patient care simulations: Role playing to enhance clinical understanding.

Nursing Education Perspectives, 26 (6) 357-361.

Dillard, N., Sideras, S., Ryan, M., Carlton, K.H., Lasater, K., Siktberg, L., (2009). A collaborative project

to apply and evaluate the clinical judgment model through simulation. Nursing Education

Perspectives 30 (2) 99-103.

Haidar, E. (2009). Clinical simulation: a better way of learning? Nursing Management

16 (5), 22-3.

Holtschneider, M., (2010). Growing the emerging field of simulation in healthcare.

Evidence-Based Staff Development. 6(3) 4-6.

Larew, C., Lessans, S., Spunt, D., Foster. & Covington, B. (2007). Innovations in clinical

simulation: Application of Benner’s Theory in an interactive patient care simulation.

Nursing Education Perspective, 27 (1) 16-19.

Lighthall, G K, Barr, J. (September 2007.) The Use of clinical simulation systems to

train critical care physicians. Journal of Intensive Care Medicine, 22, (5), 257-270.

Smith, M. (2009). Creative clinical solutions: Aligning simulation with authentic clinical experiences.

Nursing Education Perspectives. 30 (2) 126-8.

Trossman, S., (2010). These mannequins can say 'ouch!’ American Nurse, 42(1), 12-13.


Waxman, K.T. (2010). The development of evidence-based clinical simulations scenarios:

guidelines for nurse educators. Journal of Nursing Education 49 (1) 29-35.

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