The use of simulation‐based learning as an educational tool in nursing
Amanda Miller
Abstract
The use of simulation-based learning (SBL) is recognized globally as an effective teaching method to help health care practitioners learn1-3 In nursing, SBL is embedded into prelicensure programmes and is widely used in clinical practice to help qualified nurses develop their knowledge, skills and competence. Further, the inclusion of SBL in some prelicensure programmes is used to contribute to clinical practice hours. For example, the United States (US) National Council of State Boards of Nursing (NCSBN) states that 50% of practice hours can be replaced by simulation,4 although it is noted that there is variance between the states in the US. In the UK, the Nursing and Midwifery Council (NMC)5 have stated that all Higher Education Institutions (HEIs) will be permitted to apply to use 600 h of simulated practice learning, as part of the 2300 of practice hours required to qualify. In this issue of Nursing in Critical Care, two articles are included, which focus on the use of SBL and identify the benefits associated with this approach to learning. This guest editorial will discuss the use of simulation as an educational tool and how it is an effective way in helping nurses learn. “…a technique-not a technology-to replace or amplify real experiences with guided experiences that evoke or replicate substantial aspects of the real world in a fully interactive manner”6 The use of the word “technique” signifies that simulation does not need to rely on advanced technology, but that it is an educational tool that is used to imitate a real situation or environment. SBL has evolved rapidly over the last two decades, initially with the introduction of highly advanced human patient simulators, for example, SimMan®. The use of human patient simulators provides a realistic learning experience due to their ability to demonstrate physiological changes and react to interventions such as fluid and drug administration, chest drain insertion, emergency needle cricothyroidotomy and advanced life support. However, today SBL also encompasses the use of screen-based or online simulators, part task trainers, virtual and augmented reality and simulated participants (SPs). The use of SPs has become integral to the delivery of realistic simulations. SPs may play the role of the patient, family member, health care provider or other patients/bystanders. SPs provide realistic, emotive responses and interactions which are not wholly achievable with a manikin. Realism in simulation is described as having three key components: physical, conceptual and emotional/experiential.7 It is suggested that a simulation session is truly realistic when participants cannot differentiate between the simulation and actual practice. However, this is very difficult to achieve and more so, with the different modalities available to use, for example, classroom-based scenario work, reflection, video critique and critical thinking exercises. In this issue of Nursing in Critical Care, a Randomized Control Trial (RCT) research project using a simulation-based flipped classroom (SBCF) approach to teach resuscitation skills is reported on.8 This provides an example of the different approaches to SBL. “…an educational method which uses a variety of modalities to support students in developing their knowledge, behaviours and skills, with the opportunity for repetition, feedback, evaluation and reflection to achieve their programme outcomes and be confirmed as capable of safe and effective practice”. This more flexible definition should enable HEIs to be innovative in the design and facilitation of simulated practice learning, and supports the use of a variety of approaches, with the ultimate aim of providing a meaningful, quality learning experience. SBL is reported as providing significant advantages in helping nurses to learn, including improving clinical practice and increasing knowledge, critical thinking and decision-making skills.9, 10 Using simulation as an educational tool enables nurses to develop their skills in a safe learning environment and immerse themselves in a scenario with no risk to patient safety. Further, in keeping with Ericsson's theory of deliberate practice11 nurses can also use simulation to repeatedly practice specific clinical skills until they achieve mastery, such as cannulation, nasogastric intubation, and suturing. However, the SBL experience is not complete without a prebriefing and structured debriefing. Key areas for consideration in the prebriefing include preparing the learners for the simulation experience, providing a structured orientation, identifying learning objectives, reinforcing ground rules and establishing a psychologically safe learning environment.12 A specifically designed prebriefing is essential for an effective SBL experience, balancing the cognitive load for the participants, and may also improve the debriefing.13, 14 Another crucial part of the simulation experience is the debriefing, which should take place immediately after the simulation experience. The length of time dedicated to the debriefing is multifaceted and will vary according to the scenario learning outcomes and learner performance.15 However, it is suggested that the debriefing should last at least twice as long as the simulation experience.16 This is demonstrated in another research paper published in this issue of Nursing in Critical Care,17 in which each clinical vignette lasted 15 min and was immediately followed by a 30-min constructive, facilitated debriefing. Debriefing has been used in health care practice for many years as a retrospective, reflective way to evaluate and analyse critical incidents or events. In SBL, debriefing is a vital part of the learning process and must not be overlooked. Although the immersive interaction within the simulation undoubtedly helps nurses to learn, it is during the debriefing that learning opportunities are enhanced, and participants recognize their strengths and learn from their mistakes.18 The debriefing is a structured time for reflection on an SBL experience, with discussion and feedback from peers, participants and learners. In keeping with the notion of “thinking in/on action”19 such debriefing facilitates the opportunity to foster reflective practice. Further, debriefing encourages critical thinking and supports the development of complex decision-making skills.20 There are numerous models of debriefing discussed in the literature, the Diamond Debrief,21 3D model of debriefing22 and PEARLs23 to name just a few. It is important to choose a model that is applicable to the learners, the modality of SBL and one that the facilitator can use proficiently. Some facilitators may choose not to use a specific model, but it is vital that the debriefing process includes the provision of feedback, analysis of actions and impact on future practice.24 Initially learners should be encouraged to reflect on their initial thoughts and feelings and the facts of the scenario without questioning or seeking answers to problems. The analysis stage is usually the longest as it focuses on critically analysing the performance and actions of the learners, with support from the facilitator. The final stage involves summarizing the experience and identifying future areas for learning or how it might influence future practice. To summarize, research from across the globe identifies numerous benefits of using SBL, including increased self-efficacy, development of critical thinking and improved patient safety outcomes. Further, simulation provides the opportunity for nurses to practice skills in a safe environment and reduces the risk of harm to patients. The data that support the findings of this study are available from the corresponding author upon reasonable request.