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Using Virtual Patient Simulation in Substitution for Traditional Clinical Hours in Undergraduate Nursing

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In recent years, undergraduate nursing education has been facing numerous challenges as the demand for nurses continues to increase. The shortage of nursing faculty, lack of high-quality clinical places, and increased student enrollment have put a greater burden on the limited resources available in most programs (Cobbett & Snelgrove-Clarke, 2016; Foronda, Godsall, & Trybulski, 2013; Foronda & Bauman, 2014; Khalaila, 2014; Laure, Pepin, & Allard, 2015). Given these persistent challenges, many nursing programs have started to substitute students’ traditional hours with some form of simulation. In the fall of 2014, the National Council for State Boards of Nursing Simulation Study provided evidence that substituting high-quality simulation experiences for traditional clinical hours results in comparable educational outcomes in undergraduate nursing clinical courses (Hayden, Smiley, Alexander, Kardong-Edgren, & Jeffries, 2014). As the field of nursing education continues to improve this educational strategy, several studies have examined the effects of simulation on student outcomes when used in substitution for traditional clinical hours. The purpose of this research report is to examine evidence on the effectiveness of this strategy, identify best practices for its implementation across the undergraduate nursing curriculum, and discuss the role that the Shadow Health Digital Clinical Experiences™ could potentially play in improving the preparation of students as faculty adopt our virtual patient simulation into their courses.
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Using Virtual Patient Simulation in Substitution for
Traditional Clinical Hours in Undergraduate Nursing
Research Report
Francisco Jimenez, Ph.D.
Shadow Health, Inc.
201 SE 2nd Avenue, Suite 201
Gainesville, Florida 32601
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Table of Contents
Page
1. Introduction…………………………………………………………………….
2
2. The Value of Virtual Patient Simulations…………………………………....
2
3. Replacing Traditional Clinical Hours with Simulations………………..…...
4
4. Using Virtual Simulations as a Replacement for Clinical Hours………….
6
5. What Is a Good Replacement Ratio?.......................................................
8
6. Conclusions and Recommendations for Practice………………………….
9
7. List of References……………………………………………………………..
13
© 2017 Shadow Health, Inc.
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1. Introduction
In recent years, undergraduate nursing education has been facing numerous challenges
as the demand for nurses continues to increase. The shortage of nursing faculty in addition to
increased student enrollment has put a greater burden on the limited resources available in
most programs (Cobbett & Snelgrove-Clarke, 2016; Foronda, Godsall, & Trybulski, 2013;
Foronda & Bauman, 2014; Laure, Pepin, & Allard, 2015). There is also a shortage of the clinical
placements necessary to provide students with the education and experience necessary to
become a competent and autonomous professional nurse (Cobbett & Snelgrove-Clarke, 2016;
Foronda et al., 2013, 2014; Khalaila, 2014, Laure et al., 2015). Given these persistent
challenges, many nursing programs have started to substitute students’ traditional hours with
some form of simulation. In fall of 2014, the National Council for State Boards of Nursing
Simulation Study provided evidence that substituting high-quality simulation experiences for
traditional clinical hours results in comparable educational outcomes in undergraduate nursing
clinical courses (Hayden, Smiley, Alexander, Kardong-Edgren, & Jeffries, 2014).
As the field of nursing education continues to improve this educational strategy, several
studies have examined the effects of simulation on student outcomes when used in substitution
for traditional clinical hours. The purpose of this research report is to examine evidence on the
effectiveness of this strategy, identify best practices for its implementation across the
undergraduate nursing curriculum, and discuss the role that the Shadow Health Digital Clinical
ExperiencesTM could potentially play in improving the preparation of students as faculty adopt
our virtual patient simulation into their course.
2. The Value of Virtual Patient Simulations
In nursing education, simulation is usually defined as the most accurate possible
representation of a care situation and can be categorized relative to its degree of clinical fidelity:
high, intermediate, or low (Laure et al., 2015). Virtual patient simulations are considered to be
high-fidelity simulations because they are “extremely realistic and provide a high level of
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interactivity and realism for the learner” (Meakim et al., 2013, p.6). Virtual patient simulations
have been found to be comparable or superior to other high-fidelity traditional simulation
methods due to a variety of reasons. In an integrative review of 12 studies published between
2008 and 2015, Duff, Miller, and Bruce (2016) found that virtual patients and simulated
scenarios were comparable or superior to traditional simulation methods for teaching diagnostic
reasoning and assessment skills in terms of increased student learning, satisfaction, and
engagement. Among other benefits, Duff et al. (2016) concluded that these patient scenarios
were more realistic and challenging than manikins or standardized patient actors due to the
ability to create virtual scenarios including physical findings (e.g., abnormal heart rhythms or
breath sounds) that were impossible for standardized patient actors to simulate (Gesundheit et
al., 2009; Lin, Wu, Liaw, & Liu, 2012; Pucher et al., 2014; Tan, Ross, & Duerksen et al., 2013).
In the same way, other studies have found that students get more engaged with virtual
patient scenarios and value having a safe environment to practice reasoning skills before seeing
real patients in a clinical setting (De Gagne, Oh, Kang, Vorderstrasse, & Johnson, 2013;
Gesundheit et al., 2009; Lin et al., 2012; Poulton, Conradi, Kavia, Round, & Hilton, 2009). By
using asynchronous, computer-based simulations students can receive immediate and timely
feedback that can be more directly linked to the skills being practiced (Gesundheit et al., 2009).
Virtual patient scenarios can also provide transformative learning experiences for students by
challenging their prior knowledge and assumptions in light of a deeper and more meaningful
patient interaction (Kleinheksel, 2014).
The ease of access, flexibility, and cost-effectiveness of virtual patient simulations also
stand out as being benefits in comparison to other high-fidelity simulations methods (Duff et al.,
2016, Kleinheksel & Ritzhaupt, 2017). Because simulation laboratories usually require multiple
high-fidelity manikins as well as specialized faculty and technicians, setup and maintenance
costs can be very high. Moreover, for face-to-face nursing programs that have 100 or more
students, scheduling can also be complicated as working groups are normally made up with no
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more than eight students in simulation laboratories (Verkuyl, Romaniuk, Atack, & Mastrilli,
2017). And for online or blended programs, high-fidelity manikins may not be the most effective
alternative to account for hours of clinical instruction. The use of virtual patient simulations could
free faculty from having to go to multiple clinical sites in order to meet up with students and
preceptors since student performance evaluation, and even debriefing, can occur
asynchronously (Foronta & Bauman, 2014).
3. Replacing Traditional Clinical Hours with Virtual Patient Simulations
Research has shown that relevant learning outcomes with simulation are at least equal
to those achieved in traditional clinical settings in pre-licensure nursing programs. Meyer,
Connors, Hou, and Gajewski (2011) evaluated the clinical performance of 116 undergraduate
nursing students who attended a pediatric simulation instead of traditional clinical hours. During
two weeks over the course of an 8-week semester, students had 24 hours of simulation and 72
hours of clinical, resulting in a 25% substitution of simulation for traditional clinical hours.
Clinicals were composed of five groups of eight students across three different course sections,
and every two weeks, two students were selected from each clinical group to attend simulation
in place of traditional clinical. Each simulation activity had follow-up sessions of 30 minutes, and
every two weeks students were assessed by supervisor faculty on a series of outcomes
including communication skills, therapeutic nursing skills, clinical judgment, interprofessional
communication, and documentation. Results showed that, on average, students who attended
simulation had overall higher clinical performance than students who had yet to attend,
specifically when they were assigned to simulation within the first two weeks of the section.
Regarding each outcome specifically, students exposed to simulation tended to score higher in
documentation and interprofessional communication.
The National Council for State Boards of Nursing (NCSBN) conducted a large-scale,
nationwide, randomized study comparing educational outcomes between students groups
where simulation was substituted for up to 50% of traditional clinical experiences (Hayden et al.,
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2014). Results showed that there were no significant differences in nursing knowledge, clinical
competency, NCLEX pass rates, and overall readiness for professional practice when
simulation was substituted for up to 50% of traditional clinical experiences. The NCSBN study
also showed that the benefits of using simulation in lieu of traditional clinical hours in pre-
licensure nursing programs expanded to their students’ first clinical position as there were no
significant differences in clinical competency and readiness for practice at six weeks, three
months, and six months after graduation.
Other research studies have showed that undergraduate students perceived simulation
as a valuable clinical teaching model, and they reported higher confidence when compared to
their peers who only experienced traditional clinical hours (McCabe, Gilmartin, & Goldsamt,
2015; Rodriguez, Nelson, Gilmartin, Goldsamt, & Richardson, 2017). McCabe et al. (2015)
evaluated undergraduate students’ self-confidence in clinical practice under a model replacing
50% of traditional clinical hours by high-fidelity simulation in a large, urban, research intensive
university in the United States. Between the midpoint (second semester) and end of the
program (fourth semester), changes in students’ perceived self-confidence were assessed
relative to the eight clinical practice competences established by the Student Self-Assessment
of Breadth of Nursing Education (ANE): Clinical Prevention and Population Health (CPPH),
Evidence-Based Practice (EBP), 3) Generalist Nursing Practice (GNP), 4) Healthcare Policy,
Finance, Regulation (HCPFR), 5) Information Management and Application of Patient
Technology (IMAPCT), 6) Inter-professional Communication and Collaboration, 7) Organization
and Systems Leadership, and Professionalism and Professional Values (PPV). Results showed
that program time had a significant effect on students’ self-confidence on each of the eight
clinical practice competences, with students showing increases in their confidence levels from
the midpoint to the end of the program.
Rodriguez et al. (2017) examined undergraduate nursing students’ assessment of
learning in a clinical teaching model that replaced 50% of traditional clinical hours with high-
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fidelity simulation in four core medical-surgical courses at the NYU Meyers College of Nursing.
In their teaching model, simulation sessions were guided by Jeffries’ educational practices
model (Jeffries, 2005), which focuses on the principles of active learning, collaboration, diverse
ways of learning, and high expectations. In their innovative clinical teaching model, NYU Meyers
College of Nursing faculty were able to gain greater control over the range of patient scenarios
and exposure to specific clinical skills that students practice, shifting the focus to key outcomes
such as therapeutic communication, care planning and goal setting, interprofessional
collaboration, and reflective practice (Richardson, Goldsamt, Simmons, Gilmartin, & Jeffries,
2014). In their study, Rodriguez et al. evaluated students at two time points within their two-year
undergraduate program (i.e., midpoint and end of program) using a validated measure that
assessed aspects of simulation-based learning which included the four domains of Jeffries’
educational practice model. Results showed that, from midpoint to end of the program, students
indicated increases in exposure to simulation activities focused on active learning and high
expectations domains, as well as the importance of the collaboration domain.
4. Using Virtual Simulations as a Replacement for Clinical Hours
While studies have specified that the simulation used in place of traditional hours must
be “high-quality” (Hayden et al., 2014), there are several modalities of simulation that can be
used in lieu of clinical hours. Recent studies have concluded that online, virtual simulation
experiences can lead to increases in students’ knowledge and self-confidence in a similar
fashion to face-to-face traditional simulations (Cobbett & Snelgrove-Clarke, 2016, Cummings &
Connelly, 2015, Verkuyl et al., 2017). For instance, Cobbett and Snelgrove-Clarke (2016)
compared the effectiveness between a virtual clinical simulation and a face-to-face high fidelity
manikin scenario for two different maternal-newborn clinical simulations in third year
undergraduate nursing students. Results showed no significant differences in student learning
outcomes between the two simulation modalities. Given that the implementation of face-to-face
simulations can be costly and their standard equipment resource intensive, Cobbett and
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Snelgrove-Clarke suggested that online, virtual simulation experiences cannot only be less
costly but also provide students with repeated practice opportunities in a safe, standardized,
and easy-to-access environment.
Simulation activities have a positive impact on important student learning outcomes for
undergraduate nursing students when virtual simulation is used in place of traditional clinical
hours. Cummings and Connelly (2015) conducted a study where eight hours of observation
were replaced with eight hours of online simulation time for junior and senior undergraduate
nursing students. The simulation scenarios covered what students were being taught in class
(i.e., adult health I and I for junior students and professional nursing integration for senior
students), involved pre- and post-quizzes, detailed patient information, and a documentation
system, and they were delivered in groups of three to four students at the time. After one year,
students reported higher levels of self-confidence and active learning. As they went through
simulations in place of traditional clinical hours over time, students were able to identify an
improved belief in mastery of the content and confidence in their knowledge base for skills and
critical content related to adult health nursing. Students also reported improvement of their
debriefing, including their opportunities for making comments, understanding of content, and
productivity.
Verkuyl et al. (2017) conducted an experimental study comparing a pediatric nursing
virtual gaming simulation and a laboratory simulation among second-year BSN and RN-BSN
students. Students in both groups were compared regarding pediatric knowledge, self-efficacy,
and satisfaction. The pediatrics case study used was identical for both groups in terms of
learning objectives, story script, and decision points; yet feedback on the students’ progress
was built into the virtual gaming simulation. Results showed comparable gains in pediatric
knowledge and self-efficacy as well as high satisfaction scores across both groups, which
suggests that similar outcomes may be achieved with virtual gaming simulations in comparison
with traditional laboratory simulations.
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Foronta and Bauman (2014) suggested that virtual simulation may be used to count for a
portion of clinical hours, replicate high-risk clinical experiences, and act as clinical makeup.
Clinical placements are increasingly scarce and difficult to arrange, and sometimes students are
even required to pay extra fees to attend clinicals. In addition, using virtual simulations in lieu of
traditional clinical hours may exempt faculty from the burden of driving out to multiple clinical
sites to meet up with students and preceptors as evaluation of student performance and
debriefing can occur asynchronously. On the other hand, situations involving high-risk training
scenarios (premature newborn care in pediatrics, a patient presenting with PTSD in mental
health, or end-of-life situation in gerontology) may require students to practice in a low-risk, low-
anxiety environment due to safety, liability, and ethical reasons (Foronta & Bauman, 2014).
Virtual simulations may complement the existing undergraduate nursing curriculum by
incorporating these difficult and high-risk clinical experiences as well as provide an important
curriculum standardization in nursing education so that all students can have access to high-
quality, comparable educational opportunities (Baillie & Curzio, 2009, Foronta & Bauman, 2014,
Laure et al., 2015).
5. What Is a Good Replacement Ratio?
Breymier, Rutherford-Hemming, Horsley, Smith, and Connor (2015) examined the ratios
of simulation to supervised clinical hours per nursing course used, as well as the rationale for
substituting simulation in place of traditional clinical hours in over 400 pre-licensure nursing
programs in the United states. In their study, 77.5% of participants indicated that their nursing
program uses simulation in place of supervised clinical instruction. Regarding the standardized
versus unstandardized ratio of simulation substitution for clinical, 45% of participants indicated
that their nursing program used the same ratio of simulation hours to supervised hours for each
course (i.e., standardized ratio), while 55% indicated that their program did not (i.e.,
unstandardized ratio). The most common simulation to clinical time ratio among nursing
programs using standardized replacement was 1:1, with over 60% of participants reporting it.
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For nursing programs reporting unstandardized ratios, the 1:1 simulation to clinical time ratio
was also most commonly reported for core courses throughout the curriculum (e.g.,
fundamentals, medical-surgical/adult health, women’s health, mental health and pediatrics).
Curl, Smith, Chisholm, McGee, and Das (2016) also examined the effectiveness of using
high-fidelity simulations in place of 50% of traditional clinical experiences in four clinical
specialty areas: obstetrics, pediatrics, critical care, and mental health nursing. Students from
three associate degree nursing programs were assigned to either an experimental intervention
group combining simulation and clinical experiences or a control group using only traditional
learning experiences. Student learning during four hours of high-fidelity simulations (including
pre-lab and debriefing activities) was considered to be equivalent to or better than eight hours of
traditional clinical experiences (i.e., 1:2 simulation to clinical time ratio). At the end of the
research study, students in the high-fidelity simulation group performed as well as, if not better
than, students who participated in the traditional hours group on a standardized measure of
medical-surgical knowledge. Both groups also yielded comparable NCLEX-RN pass rates. Over
95% of the students in the high-fidelity simulation reported that the simulation experience
improved their critical thinking and increased their confidence in technical skills. Faculty’s
evaluation of students’ performance also reported that near 50% of the students showed above
average critical thinking competency.
6. Conclusions and Recommendations for Practice
Nursing education and simulation experts who have further discussed the results and
significance of the NCSBN Simulation Study agree on the fact that this study provided the
needed evidence to support the claim that simulations work as a replacement of traditional
clinical experiences in undergraduate nursing education (Rutherford-Hemming, Lioce, Kardong-
Edgren, Jeffries, & Sittner, 2016). In the past three years, additional studies have contributed to
an emerging body of research evidence regarding the value of simulation-based approaches in
improving learner preparation and practice when used in place of traditional clinical hours.
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Several conclusions can be drawn from this research report. First, virtual patient
simulation can be defined as high-fidelity given their degree of realism and high level of
interactivity for the learner. However, not every virtual patient simulation can be considered
high-fidelity. The Shadow Health Digital Clinical ExperienceTM is an online, asynchronous virtual
patient clinical simulation that allows undergraduate nursing students to demonstrate and
practice their clinical reasoning skills through life-like interactions with Digital Standardized
PatientsTM. Through an immersive experience powered by a conversation engine, students can
practice taking a detailed health history, perform physical assessments in single-system exams,
and conduct focused exams to rule out causes of a chief complaint. In addition, each
assignment provides students with immediate feedback on several aspects of their performance
using the Student Performance IndexTM, which measures students’ clinical reasoning skills as
they relate to subjective data collection, objective data collection, information processing, and
the students’ ability to identify opportunities to engage in therapeutic communication.
Second, virtual patient simulation is comparable, if not superior, to other forms of high-
fidelity simulation. This research report shows that undergraduate nursing students have found
virtual patient simulations to be more realistic and challenging than manikins and standardized
patients. In addition, the use of simulation can lead to increases in student engagement, self-
confidence, and satisfaction. Foronda et al. (2014) stated that virtual simulation can be used in a
complementary way to support the existing undergraduate nursing curriculum. Besides
providing students with a low-risk environment where students can practice new skills and apply
new knowledge, virtual simulation like the Shadow Health Digital Clinical ExperienceTM allows
educators to foster student outcomes through a uniform learning experience, and as a result,
students can be more in control of their learning (Laure et al., 2015).
Third, the Shadow Health Digital Clinical ExperienceTM also addresses the challenges
brought up by other forms of high-fidelity simulations, especially in these times when there is a
deficiency in the clinical hours available to nursing students and quality clinical placements
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brings are difficult to secure for traditional and nontraditional students. Compared to manikins or
standardized patients, virtual patient simulations offer several benefits in terms of cost-
effectiveness, flexibility, and ease of access (Duff et al., 2016). Virtual patient simulations do not
require the financial investment or clinical lab space of high-fidelity patient simulators, which
becomes an advantage for online and blended nursing programs (McKeon, Norris, Cardell, &
Britt, 2009, Kleinheksel & Ritzhaupt, 2017). Virtual patient simulations do not require the time
and costs associated to training a standardized patient actor, or the schedule and space
restrictions posed by large sections of students having to work with a single standardized
patient actor (Kleinheksel & Ritzhaupt, 2017).
Finally, national surveys show that the most common simulation to clinical time ratio
among nursing programs using the simulation-based replacement approach is 1:1. Several
research studies show that exposure to simulation up to 50% results in increases in clinical
knowledge, critical thinking, debriefing skills, self-confidence, NCLEX pass rates, and overall
readiness for professional practice. Unlike other forms of high-fidelity simulation, the Shadow
Health Digital Clinical ExperienceTM provides an off-campus environment to allow students to
engage in open-ended conversations to practice patient-centered communication. In addition,
the Shadow Health Digital Clinical ExperienceTM offers a wide variety of clinical scenarios and
patient cases for core courses in the nursing curriculum like health assessment, pharmacology,
mental health, and gerontology, where students can gather subjective data, practice recording
objective patient data, and synthesize their findings. For distance education students who do not
have access to a simulation lab or clinical sites, faculty can use the Shadow Health Digital
Clinical ExperienceTM as a summative assessment in order to count for hours of clinical and
evaluate the competency of their students (Kleinheksel & Ritzhaupt, 2017).
This research reports lays out the multiple advantages for students when virtual patient
simulation is used in place of traditional clinical hours. Student outcomes such as clinical
competency, critical thinking, content knowledge and self-confidence can be successfully
© 2017 Shadow Health, Inc.
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achieved through the meaningful use of the Shadow Health Digital Clinical ExperienceTM. As the
field of nursing education moves forward with this trend, it becomes critical to promote the value
of simulation by translating its importance in terms of providing better, quality care and patient
outcomes (Rutherford-Hemming et al., 2016).
© 2017 Shadow Health, Inc.
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7. List of References
Baillie, L., & Curzio, J. (2009). Students’ and facilitators’ perceptions of simulation in practice
learning. Nurse Education in Practice, 9(5), 297-306.
Breymier, T. L., Rutherford-Hemming, T., Horsley, T. L., Atz, T., Smith, L. G., Badowski, D., &
Connor, K. (2015). Substitution of clinical experience with simulation in prelicensure
nursing programs: A national survey in the united states. Clinical Simulation in Nursing,
11(11), 472-478.
Cobbett, S., & Snelgrove-Clarke, E. (2016). Virtual versus face-to-face clinical simulation in
relation to student knowledge, anxiety, and self-confidence in maternal-newborn nursing:
A randomized controlled trial. Nurse Education Today, 45, 179-184.
Cummings, C. L., & Connelly, L. K. (2016). Can nursing students' confidence levels increase
with repeated simulation activities?. Nurse Education Today, 36, 419-421.
Curl, E. D., Smith, S., Chisholm, L. A., McGee, L. A., & Das, K. (2016). Effectiveness of
integrated simulation and clinical experiences compared to traditional clinical
experiences for nursing students. Nursing Education Perspectives, 37(2), 72-77.
De Gagne, J. C., Oh, J., Kang, J., Vorderstrasse, A. A., & Johnson, C. M. (2013). Virtual worlds
in nursing education: A synthesis of the literature. Journal of Nursing Education, 52(7),
391-400.
Foronda, C., & Bauman, E. B. (2014). Strategies to incorporate virtual simulation in nurse
education. Clinical Simulation in Nursing, 10(8), 412-418.
Foronda, C., Godsall, L., & Trybulski, J. (2013). Virtual clinical simulation: the state of the
science. Clinical Simulation in Nursing, 9(8), e279-e286.
Duff, E., Miller, L., & Bruce, J. (2016). Online virtual simulation and diagnostic reasoning: A
scoping review. Clinical Simulation in Nursing, 12(9), 377-384.
Gesundheit, N., Brutlag, P., Youngblood, P., Gunning, W. T., Zary, N., & Fors, U. (2009). The
use of virtual patients to assess the clinical skills and reasoning of medical students:
© 2017 Shadow Health, Inc.
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Initial insights on student acceptance. Medical Teacher, 31(8), 739-742.
Hayden J. K., Smiley R. A., Alexander M., Kardong-Edgren, S., & Jeffries, P. R. (2014). The
NCSBN national simulation study: A longitudinal, randomised, controlled study replacing
clinical hours with simulation in prelicensure nursing education. Journal of Nursing
Regulation, 5(2), S4-S41.
Jeffries, P. R. (2005). A framework for designing, implementing, and evaluating simulations
used as teaching strategies in nursing. Nursing Education Perspectives, 26(2), 96103.
Khalaila, R. (2014). Simulation in nursing education: an evaluation of students' outcomes at
their first clinical practice combined with simulations. Nurse Education Today, 34(2),
252-258.
Kleinheksel, A. J. (2014). Transformative learning through virtual patient simulations: predicting
critical student reflections. Clinical Simulation in Nursing, 10(6), e301-e308.
Kleinheksel, A. J., & Ritzhaupt, A. D. (2017). Measuring the adoption and integration of virtual
patient simulations in nursing education: An exploratory factor analysis. Computers &
Education, 108, 11-29.
Laure, C., Pepin, J., & Allard, É. (2015). Simulation in preparation or substitution for clinical
placement: A systematic review of the literature. Journal of Nursing Education and
Practice, 5(9), 132-140.
Lin, C. C., Wu, W. C., Liaw, H. T., & Liu, C. C. (2012). Effectiveness of a virtual patient program
in a psychiatry clerkship. Medical Education, 46(11), 1111-1112.
McCabe, D. E., Gilmartin, M. J., & Goldsamt, L. A. (2016). Student self-confidence with clinical
nursing competencies in a high-dose simulation clinical teaching model. Journal of
Nursing Education and Practice, 6(8), 52-58.
McKeon, L. M., Norris, T., Cardell, B., & Britt, T. (2009). Developing patient-centered care
competencies among prelicensure nursing students using simulation. The Journal of
Nursing Education, 48(12), 711-715.
© 2017 Shadow Health, Inc.
All Rights Reserved. 15
Meakim, C., Boese, T., Decker, S., Franklin, A. E., Gloe, D., Lioce, L., & Borum, J. C. (2013).
Standards of best practice: Simulation standard I: Terminology. Clinical Simulation in
Nursing, 6(9), S3-S11.
Meyer, M. N., Connors, H., Hou, Q., & Gajewski, B. (2011). The effect of simulation on clinical
performance: A junior nursing student clinical comparison study. Simulation in
Healthcare, 6(5), 269-277.
Poulton, T., Conradi, E., Kavia, S., Round, J., & Hilton, S. (2009). The replacement of ‘‘paper’’
cases by interactive online virtual patients in problem-based learning. Medical Teacher,
31(8), 752-758.
Pucher, P. H., Batrick, N., Taylor, D., Chaudery, M., Cohen, D., & Darzi, A. (2014). Virtual-world
hospital simulation for real-world disaster response: design and validation of a virtual
reality simulator for mass casualty incident management. Journal of Trauma and Acute
Care Surgery, 77(2), 315-321.
Richardson, H., Goldsamt, L. A., Simmons, J., Gilmartin, M., & Jeffries, P. R. (2014). Increasing
faculty capacity: Findings from an evaluation of simulation clinical teaching. Nursing
Education Perspectives, 35(5), 308-314.
Rodriguez, K. G., Nelson, N., Gilmartin, M., Goldsamt, L., & Richardson, H. (2017). Simulation
is more than working with a mannequin: Student’s perceptions of their learning
experience in a clinical simulation environment. Journal of Nursing Education and
Practice, 7(7), 30-36.
Rutherford-Hemming, T., Lioce, L., Jeffries, P. R., & Sittner, B. (2016). After the National
Council of State Boards of Nursing Simulation Studyrecommendations and next steps.
Clinical Simulation in Nursing, 12(1), 2-7.
Tan, A., Ross, S. P., & Duerksen, K. (2013). Death is not always a failure: outcomes from
implementing an online virtual patient clinical case in palliative care for family medicine
clerkship. Medical Education Online, 18.
© 2017 Shadow Health, Inc.
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Verkuyl, M., Romaniuk, D., Atack, L., & Mastrilli, P. (2017). Virtual gaming simulation for nursing
education: An experiment. Clinical Simulation in Nursing, 13(5), 238-244.
... Nursing education is considered a practice-based profession. Having qualified graduates depends on the quality of their clinical training and level of competencies they achieve [1]. Undergraduate nursing education has been facing numerous challenges due to shortage of academic and clinical staff compared to the increased number of students, limited clinical placements, and use of highly developed technology in the clinical field [2][3][4]. ...
... Regardless of the different competencies and different fields of care, the results of this study support previous studies conducted to assess the confidence level during caring of critical care patients [6,8,9,17]. Using simulation in teaching strengthens students' fundamental skills, creates a safe environment for practice, and increases opportunities to repeat the procedures; thus, it will increase self-confidence [1,6,39]. ...
Article
Background: High-fidelity simulation (HFS) as a teaching-learning method has increased, especially in medical programs. Objective: This study was conducted to assess the effectiveness of using HFS on the satisfaction, self-confidence, self-efficacy, and knowledge of undergraduate students in oncology care. Methods: A pre-test post-test quasi-experimental design was utilized. Random sampling technique was used to recruit the participants. The scenarios including septic shock and infusion reaction were implemented. The training program including lectures and the simulation was run in a high fidelity simulation lab. Results: There was a significant difference (t=-5.95, p= 0.001) between the experimental group (M= 13.95, S⁢D= 3.35) and the control group (M= 6.25, S⁢D= 2.65) regarding knowledge, confidence (t=-22.75, p= 0.001) between the experimental group (M= 61.25, S⁢D= 12.10) and the control group (M= 38.50, S⁢D= 6.20), satisfaction level t=-18.25, p= 0.001; experimental group - M= 42.25, S⁢D= 4.25; and control group - M= 28.50, S⁢D= 3.15), and there was a significant difference between the experimental group (M= 35.50, S⁢D= 3.25) and control group (M= 24.25, S⁢D= 2.85) regarding self-efficacy (t=-13.25, p= 0.001). Conclusions: High-fidelity simulation in nursing increased student knowledge, self-confidence, satisfaction, and self-efficacy in managing septic shock and infusion reaction as common oncology emergencies.
... La evidencia apoya el uso de una proporción de 2 horas clínicas por 1 hora de simulación cuando se usa para la sustitución de experiencias clínicas tradicionales, validado mediante la realización de actividades que demuestran niveles más altos de competencia clínica en un tiempo significativamente menor que las experiencias clínicas tradicionales cara a cara (Jiménez, 2017;Sullivan et al., 2019). ...
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Introducción: en el contexto de la pandemia mundial por COVID-19 se incorporan nuevas metodologías de enseñanza-aprendizaje para contribuir al logro de los objetivos de aprendizaje frente al cierre de las universidades y de los campos clínicos. Esta investigación evalúa la percepción y la experiencia de los estudiantes de tercer y cuarto año de pregrado de enfermería, frente al uso de escenarios de simulación virtual como complemento de la práctica clínica. Materiales y métodos: un total de 68 estudiantes (26%) respondieron la encuesta de percepción sobre su experiencia del uso de la simulación virtual a través del software vSim for Nursing™. Se realizó un análisis cuantitativo y cualitativo de los datos. Resultados: un 89,7% de los estudiantes consideraron que la simulación virtual es útil para el aprendizaje y que contribuye principalmente para la comprensión de los contenidos y desarrollo de las habilidades de valoración clínica. Discusión: la experiencia en la simulación virtual es realista y útil tanto para aprender nuevos conocimientos, para reforzar los saberes previos y así también como una buena preparación para la práctica clínica. Se visualiza su incorporación desde el inicio al término de la carrera. Sin embargo, para áreas como salud mental otras metodologías podrían ser más adecuadas para mejorar las habilidades de comunicación.
... Moreover, the results of the current study demonstrated increases in nurses' selfconfidence after the intervention. Continuing education and training increase nurses' skills, provide safe practice and provide nurses with constructive feedback, leading to an increase in self-confidence [27][28][29]. In this study, the oncology nurses felt more confident to take on responsibilities in nutritional assessment and counselling for cancer patients. ...
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Objective: Our objective was to assess the effectiveness of a structured educational program on improving oncology nurses' knowledge, self-confidence, and self-efficacy in nutritional assessment and counseling for patients with cancer. Methods: A pretest-posttest quasi-experimental design was used. A sample of 60 nurses from oncology units participated as an experimental group (n = 30) and a control group (n = 30). The participants completed a knowledge test before completing the educational program. Self-confidence and self-efficacy also were assessed pre- and postintervention. Results: There was a significant difference between the experimental (mean [M] = 26.00, SD = 8.00) and control (M = 10.00, SD = 3.75) groups regarding knowledge after the interventional sessions (t = -16.00, P = 0.001). Furthermore, the results indicated a significant difference (t = -24.00, P = 0.001) between the experimental group (M = 60.50, SD = 13.10) and the control group (M = 36.50, SD = 7.60) regarding self- confidence in managing cancer patients. Finally, there was a significant difference between the experimental group (M = 33.50, SD = 3.10) and control group (M = 23.25, SD = 2.75) regarding self-efficacy (t = -10.25, P = 0.001). Conclusions: The educational program improved the oncology nurses' knowledge, self-confidence, and self-efficacy in relation to nutritional assessment and counseling. Improving nurses' competencies will improve the quality of care provided to the patients and patient health outcomes.
... [27][28][29][30] Using educational program strengthens nurses' skills, improves safety, and increases opportunity to learn, and thus, it will increase the self-confidence. 29,[31][32][33] Formal and well-planned training and education lead to improved patient outcomes, prevent complications, and reduce cost of treatment. 19,34 The present study recommends oncology units' responsibility to encourage continuous learning for the nurses. ...
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The aim of the present study was to assess the effectiveness of implementing an educational module based on the Centers for Disease Control and Prevention guidelines on the nurses’ knowledge and self-confidence regarding central line catheters (CVCs) caring, complications, and application. A pretest-posttest quasi-experimental design was used. A sample of 100 oncology nurses from oncology units participated in two groups, experimental group (N = 50) and control group (N = 50). The participants completed knowledge test and self-confidence scale before and after the educational program. The results showed that there was a significant difference between the experimental and control groups regarding knowledge related to CVC guidelines and management after the interventional sessions (t = −7.85, P =.001). The mean and standard deviation for experimental group were 15.95 (5.45) and 7.35 (2.73) for the control group. Furthermore, the results showed significant difference (t = −22.20, P =.001) between the experimental group (M = 61.50, SD = 14.20) and the control group (M = 35.50, SD = 7.20) regarding self-confidence in managing CVCs. It is concluded that using educational program strengthens nurses’ skills, improves safety, and increases opportunity to learn, and thus, it will increase the self-confidence. © 2018 Society for Vascular Nursing. Published by Elsevier Inc. All rights reserved.
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AIM The focus of this research study was the evaluation of the effectiveness of using high-fidelity simulations to replace 50 percent of traditional clinical experiences in obstetrics, pediatrics, critical care, and mental health nursing. BACKGROUND Increasing student admissions to nursing programs require additional clinical learning opportunities to accommodate extra students. METHOD Three schools with associate degree nursing programs partnered to identify, implement, and evaluate a creative solution to this dilemma. The resulting quasi-experimental study investigated if substituting half of the conventional clinical experiences with simulations was as effective as traditional clinical activities in obstetrics, pediatrics, mental health, and critical care. One hour of simulation counted for two hours of clinical time. RESULTS Findings indicated combining simulations with conventional clinical experiences resulted in significantly higher scores on the pre-graduation exit exam than traditional clinical experiences alone. CONCLUSIONS Findings have implications for articulation and basic students in associate degree nursing programs.
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Objective: This paper describes undergraduate nursing students’ assessment of confidence in clinical practice within a modelthat uses a “high-dose” of clinical simulation to replace 50% of the traditional clinical experience hours in an upper division bachelor’s degree program. We assessed changes in self-reported confidence between the middle and end of a two-year nursingcurriculum. Design: Longitudinal design. We surveyed undergraduate nursing students to assess their perceived self-confidence in carryingout eight core competencies associated with generalist nursing practice with the Assessment of Nursing Education Scale (Robert Wood Johnson Foundation, 2009) at the mid-point (semester 2) and end of program (semester 4). Methods: Data were analyzed Generalized Linear models. To account for changes over time, we included program track(traditional BSN or 15-month accelerated second degree program) and gender (male/female) as co-variates in the models. Results: One hundred and twenty-two students completed the ANE at the two time points. Results for analysis of student confidence over time showed significant improvement on each of the eight domains of generalist nursing practice. There was nosignificant effect of gender or program type on student’s perceived self-confidence. Conclusions: Overall significant improvement in students’ self-assessed confidence from program mid-point to end-point lends support to the efficacy of a clinical teaching model that uses a high dose of simulation to substitute for traditional clinical hours.
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Background The Digital Clinical Experience™ is a simulation software that allows nursing students to interview and examine virtual patient and then write self-reflections on their performance. Methods A secondary data analysis was conducted on 130 master of science in nursing students' performance in the Digital Clinical Experience™ using a framework of situated cognition and transformative learning theory. Employing a within-stage mixed-model design, content analysis of structured self-reflections was conducted using Cook's Reflection Rating Rubric. Multiple regression was performed using self-reflection scores as the dependent variable; independent variables included time spent in simulation, lines of dialog, and primary and secondary clinical items discovered. Results Critical self-reflection indicating transformative learning was predicted by the number of secondary clinical items students uncover during their virtual patient interview. Yet, this level of self-reflection did not occur for students who discovered only the primary clinical findings. Conclusions This study presents evidence that virtual patient simulations can provide transformative learning experiences in nursing. However, to facilitate a transformative learning experience, these simulations must allow students to explore the presentation, history, and backstory of the virtual patient in depth, beyond superficial clinical findings.
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This study sought to develop a valid and reliable instrument to identify the characteristics of computer-based, interactive, and asynchronous virtual patient simulations that nurse educators identify as important for adoption, and the subsequent curricular integration strategies they employed. Once these factors were identified, this study also sought to explore any relationships between the influential features for adoption and the ways in which the adopted virtual patients are integrated. Data were collected with the Virtual Patient Adoption and Integration in Nursing (VPAIN) survey, which was completed by 178 nurse educators who were currently or had used virtual patient simulations. Both exploratory factor analysis and correlation analysis were conducted. Through exploratory factor analysis, 55.6% of the variance in the VPAIN adoption subscale data was accounted for by the nine adoption factors identified: Trustworthiness, Worldbuilding, Pedagogy, Differentiation, Encouragement, Clarity, Evaluation, Administrative Pressure, and Visibility. The factor analysis also identified five factors within the integration subscale, which accounted for 53.3% of the variance: Hour Replacement, Intensive Integration, Leveling, Preparation, and Benchmarking. A correlation analysis was conducted to identify relationships between the adoption and integration factors.
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Background: Virtual reality technology can range from bedside learning to computerized tools accessed exclusively online; yet there is little evidence of the effectiveness of online virtual simulation for teaching diagnostic reasoning to health care providers. To address this gap, an examination of virtual simulation encounters in the online classroom was undertaken to inform education of a variety of health care providers, including nurse practitioners, registered nurses, and physicians. Method: Arskey and O'Malley's (2005) framework was the methodology used to conduct the scoping review. Result: Twelve studies published between 2008 and 2015 were identified from a search of 14 databases. The study sample included physicians and medical students (seven), baccalaureate nursing students (two), associate degree nursing students (one), and providers from other fields such as pharmacists, physiotherapists, sports medicine, forensics, and veterinarians. Conclusion: Online virtual simulation was comparable or superior to traditional simulation methods where increased engagement with learning occurred in a safe environment with convenient access. © 2016 International Nursing Association for Clinical Simulation and Learning.
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In 2014, nursing faculty conducted a study with undergraduate nursing students on their satisfaction, confidence, and educational practice levels, as it related to simulation activities throughout the curriculum. The study was a voluntary survey conducted on junior and senior year nursing students. It consisted of 30 items based on the Student Satisfaction and Self-Confidence in Learning and the Educational Practices Questionnaire (Jeffries, 2012). Mean averages were obtained for each of the 30 items from both groups and were compared using T scores for unpaired means. The results showed that 8 of the items had a 95% confidence level and when combined the items were significant for p <.001. The items identified were those related to self-confidence and active learning. Based on these findings, it can be assumed that repeated simulation experiences can lead to an increase in student confidence and active learning.
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Background: In recent years, nursing education has undergone changes and restructuring due to changes that have occurred in clinical and academic settings. Currently, academic leaders are facing the challenges of an increasing number of students, the difficulty of recruiting teachers and preceptors to accompany students, and fewer clinical settings that can accommodate many interns at once. To come to terms with these changes, the idea of replacing clinical hours with simulation has emerged. On this issue, little conclusive data is available. The objective of this article is to clarify the contribution of simulation in clinical nursing education in preparation or substitution for clinical placement. Methods: The CIHNAL, MedLine, and PubMed databases, and Google and Google Scholar search engines were consulted between to conduct a systematic review of the literature between 2008 and 2014. Thirty-three articles were selected. Results: Students and teachers perceive the benefits of simulation as an adjunct to clinical placement in terms of effectiveness, self-confidence, and preparation for clinical practice. Substituting clinical placement with simulation does not seem to have a significant impact on clinical competency, critical thinking, knowledge acquisition, and self-confidence. Conclusions: The findings question the very concept of substitution and suggest that the strengths of clinical exposure through both simulation and clinical placement should be highlighted.
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The Institute of Medicine Report The Future of Nursing: Leading Change, Advancing Health provides direction for educators to use simulation and Web-based learning. Virtual clinical simulation (VCS) is an innovative approach offering Web-based simulations. The aim of this article is to provide an integrative review of the literature and explore the state of the science of VCS in nursing.Method The Cumulative Index to Nursing and Allied Health Literature database and Medline were explored, and 86 articles were selected as relevant and reviewed.ResultsOnly 3 studies were located that formally examined the use of VCS in nursing.ConclusionVCS is an emerging educational venue that warrants further investigation.
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Virtual simulation, using avatars through synchronous, multiplayer virtual worlds, is an engaging and meaningful way to teach high-level skills online in nurse education. The aim of this article was to present strategies for incorporation of virtual simulation in nurse to education and to provide an approach to get started. Virtual simulation may be used by educators to enhance lecture or web-based courses, replicate high-risk clinical experiences, act as clinical makeup, foster intradisciplinary and interdisciplinary education, and address practical challenges and barriers to contemporary nursing education.