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Nursing Standardized Simulation

Nursing Standardized Simulation

Simulation is a teaching method and strategy for learning and comprehending theoretical knowledge and skills in the nursing and medical fields.

Objective: To review and present current data on this topic.

Methods: In English, a literature review of data related to the issue was conducted using the keywords nursing, simulation, simulator, and nursing laboratory from the Medline, Cinhal, and Scopus databases.

The use of simulation allows students to practice their clinical and decision-making skills for some significant issues they may face in their daily work: the safe environment and sense of security boost students’ self-esteem and confidence, which promotes learning. The gap between theory and practice is thus significantly reduced.

Conclusion: The continued development of simulation and other instructional techniques can significantly aid students’ efforts to become integrated and successful healthcare professionals.
Nursing, simulation, simulator, and nursing laboratory are all keywords.
1. INTRODUCTION One of the most severe issues in nursing education is a lack of coordination between theory and practice. Nursing students need help applying theoretical knowledge in practice, a global issue (1, 2). The distance created between theory and practice complicates the learning process, and the lack of understanding of nursing terms and concepts affects the professional integration of a student (3). (3). This is achieved through accurate knowledge and understanding of healthcare science, where nursing theory is harmoniously combined with practical skills. A teaching technique contributing to this direction is simulation.

Simulation is “the process by which we are trying to achieve results approximating clinical practice as closely as possible”. It is a method of replacing or supplementing real-life experiences with guided experiences that are a faithful imitation of the natural world in a fully interactive manner (4). It is a teaching method in which students experience the actual dimensions of their future professional roles by following a specific scenario, allowing them to be more quickly integrated into the healthcare workforce (5, 6)

Simulation is used in nursing science to teach theoretical and clinical skills while promoting students’ critical thinking (7, 8). Simulation allows students to work in an environment similar to a hospital, allowing them to gain healthcare and nursing experience before they begin working as professionals. The students can put everything they’ve learned into practice, deal with difficulties and problems, and even make mistakes without causing harm, all in a safe environment with no risk to patients (9, 10). The increased use of simulation is due to a lack of clinical structures for student training, a shortage of professors, and the improved quality of training provided by this method (11).

The goal of this study was to review and present current data on this topic.

This descriptive study is based on literature data derived from online databases: Medline, Cinhal, and Scopus (in English), using the keywords: nursing, simulation, simulator, and nursing laboratory.

Simulation-based education
Simulation is a teaching and training technique for healthcare professionals that aims to significantly improve, enhance, and disseminate knowledge, skills, and attitudes of healthcare professionals at all levels. Students experience and interact in an actual hospital setting using this technique, which significantly reduces the likelihood of errors in the performance of their duties (4, 12).

Simulation-based education and learning is a response to students’ theoretical training, assisting them in developing knowledge, skills, and attitudes while creating a sense of security for both the patient and the healthcare professional (13). This technique rebuilds a skill or clinical experience, in whole or part, without putting patients at risk (14, 15). It is mainly used in countries with limited educational resources to apply structured learning experiences (e.g., venipuncture, patient resuscitation) based on a specific action protocol, as well as to improve team spirit and cooperation (16, 17). This technique reduces errors, increases students’ satisfaction with the educational process, and boosts their self-confidence, self-esteem, and comfort with skill performance. The students are now familiar with the sequential steps required to learn a skill, perfect their technique, and achieve the best clinical outcome. Simulation-based education and learning become interactive and experiential, with the primary benefit being the consolidation of acquired skills and knowledge (18-20). The environment in which the simulation is carried out encourages learning, and through repetition of a skill, this skill becomes fully understood and clear. Wellard et al. (21) report in their work that the safe environment of a laboratory practically forces students to learn and understand specific skills, whereas Freeth et al. (22) argue that clinical laboratories and simulation significantly reduce student anxiety and fear. By selecting rare or unusual examples or scenarios, students become acquainted with various interventions and skills, thereby improving educational effectiveness (23). Croxon et al. (24) conducted a study in which students commented positively and strongly argued that simulation and clinical laboratory procedures had prepared them for what they would face in the hospital.
Nursing Standardized Simulation
Simulation can teach basic nursing skills such as intramuscular and intravenous drug administration, venipuncture, nasogastric catheter placement, colostomy care, bladder catheterization, oxygen therapy, and basic life support lessons.

Another fundamental feature of simulation is the ability to assess student performance because step-by-step learning allows for repetition and testing (25).

Types of Simulations in Nursing Education
An attempt is made to replace actual patients with virtual standardized patients or technologies and methods capable of reproducing actual clinical scenarios for therapeutic and educational purposes using simulation. These processes include, for example, the simple demonstration of a specific scenario on a computer (cognitive test), the simulation of a nursing skill, or the execution of an integrated process. The following are the basic types of simulation in nursing education (15, 25, 26, 27):

High-fidelity mannequins or technologies are used.
These are body blocks or body part blocks with life-like characteristics that can respond to student actions or interventions. They represent a patient’s clinical reactions-symptoms and describe any conditions surrounding a case, such as tool stocks (e.g., dressings, syringes, etc.) and time limits.

Mannequins with low fidelity.
Low-fidelity mannequins can perform a limited number of specific tasks or processes, such as a limb for catheterization of a vessel or a dummy for CPR training.

Simulators of partial tasks.
This category includes models (e.g., hands-arms) used to demonstrate a clinical skill task that students can repeat. Examples include “limbs” for intravenous catheterization of a vessel, head and chest mannequins for airway placement, and faux leather cushions for wound suturing practice.

VR stands for virtual reality. Virtual reality is becoming more popular as a simulation tool. Virtual reality simulation employs computers and standardized patients in the health professions to create a realistic learning and evaluation environment.

Volunteers who play the roles of patients are known as standardized patients.
These trainees act in a specific manner in preparation for realistic clinical interactions. They are widely used in nursing education for teaching and assessment, particularly for communication and skill acquisition, and they may provide feedback when requested.

Online education (usually knowledge testing, e.g., multiple tests).
Computer simulators are representations of tasks or settings that aid learning. These can range from a simple computer program demonstrating the operation of a device, such as an anaesthetic machine, to something much more complex, such as a detailed virtual reality setting in which participants interact with virtual patients or other healthcare professionals.

Simulation of hybrid systems.
This type of simulation is defined as combining two or more simulation types to create a more realistic simulation experience. A typical example is the use of portable devices by standardized patients, in which students can perform specific procedures while interacting with a natural person. For example, a standardized patient may attach a suture training model (cushion) to their arm, where the trainee can suture a wound while obtaining informed consent, explaining the procedure, and so on.

Patient Simulation Benefits in Nursing Education
Simulation emerged as an evidence-based educational technique and process when it became difficult for nurses working in hospitals to gain clinical experience. Simulation helps to address any limitations related to the clinical setting (such as patient availability, security issues, and so on), promote teamwork and solidarity among students, and implement a protocol for skill attainment. It is based on a scenario in which learning becomes interactive, feedback between the educator and the other team members is allowed, and clinical reasoning and critical thinking are promoted in the team (28).

Most students are acquainted with cutting-edge computer technology and computer games. As a result, there is a degree of comfort with certain types of computer simulation, particularly those that provide audio and video feedback in real-time, assisting a student even more in performing a skill. Another factor that leads a student to success and knowledge is the controlled and utterly safe setting (both for the patient and for the student) of a laboratory where a professor may operate. Furthermore, an activity may be interrupted for discussion and correction and resumed later. The evaluation of activity by the student and the professor is greatly aided by video recording of skill (29).

According to Cook et al. (30), simulation strengthens healthcare systems by fostering interprofessional development of the team of healthcare professionals, improving the overall performance of activities and healthcare skills, and increasing healthcare professionals’ competence in a safe setting. Feedback topics could include error analysis, communication-related issues, and missed opportunities to improve health care.

Simulation aids in developing various scenarios that require nurses to use clinical and critical thinking skills to solve problems. Furthermore, according to Savarese (31), there is a trend in nursing school curricula to replace hospital clinical experience with simulation programs, even up to 50%.

The area where simulation is performed, psychosocial contact and interaction of students, organization and teaching elements are all factors that may influence learning outcomes and promote student self-confidence (32). Teaching is an experiential exercise centred on training and cooperation with others that focuses on students (33).

Nursing students can practice their abilities and clinical skills through simulation, make mistakes that are not fatal to the patients, and repeat the process (more than once) to achieve mastery. Furthermore, they have time to reexamine and reflect on their performance and reach a kind of review, which is required for the process to be completed (34, 35).

This process allows students to participate actively and is focused on error prevention, immediate feedback, and the creation of an appropriate training environment in which students can feel and be psychologically safe, communicate among themselves and review the process. Participation in small groups allows students to directly monitor their classmates’ efforts, improve their methods, and increase solidarity among them (36, 37). Simulation bridges the gap between theory and clinical practice. Students can understand a skill by seeing and practising it on a patient simulator. As a result, critical thinking develops, and clinical decision-making skills lead to significant learning opportunities (38).

It is well established that simulation-based training improves communication skills, the ability to collaborate with other interdisciplinary team members, the ability to manage complex situations, and self-efficacy and understanding of interpersonal relationships (39, 40).

According to Crowe et al. (41), simulation can improve nursing knowledge and skills, promote communication, and boost nurses’ confidence and self-reliance in performing their duties. As a result, they are less stressed, more confident, have improved psychomotor skills, and are better prepared to apply nursing interventions in a clinical setting.

Currently, simulation-based training has a variety of applications as an educational tool in nursing science. Recent applications include continuing vocational education, just-in-time training, and team building. Educators play an essential role in regulating the entire procedure, facilitating learning through their knowledge and skills. Educators also ensure that a psychologically safe environment is created for students to act in this setting, reducing other concerns and problems they may have (42).

Simulation’s Use in Nursing Education: Limitations
Simulation is widely used in nursing schools and is spreading because the benefits are enormous. However, there are some limitations to teaching nursing skills through simulation, the most important of which are as follows:

Simulation as a technique and holistic nursing care as a philosophy are two distinct components of nursing courses that have been merged in acquiring patient care knowledge and skills. Through the use of simulators, standardized patients, and virtual settings, simulation allows for the acquisition and application of knowledge and skills. However, approaching a patient as a whole, as a biopsychosocial human being, is impossible (43).

Another limitation of simulation training is that not all variables associated with an emergency in a real-world environment are always included. Simulation training is conducted in a controlled environment overseen by an educator, who can halt and restart a process, which is impossible in real life (29).

Simulation is a process that attempts to mimic real life, but it is not real. Its realism is determined by the simulator’s fidelity, the setting, and the scenario description. Even with the most advanced simulation models, there will always be an imperfect imitation of human systems. Regardless of how well-trained the students are, when called upon to apply a skill in real-time and in conditions, they frequently become highly stressed or “freeze,” rendering them unable to complete the procedure successfully. As a result, schools are attempting to update various simulation programs, invest in machinery, or use actors in the roles of patients to add plausibility to their reactions. Furthermore, professors must be trained in simulation processes and technological issues. As realism improves, so does the effectiveness of simulation and scenarios as a training tools (44, 26).

Nursing education, in whatever form it takes, is costly, especially if it is done through simulation. A modern laboratory’s equipment and operation are pretty expensive. The purchase of computers and high-fidelity simulation models, as well as their maintenance, require significant funds. Amortization of such equipment will be accomplished through appropriate and rapid student training and, as a result, from the health care provided to patients by well-trained nurses (45, 46).

In general, familiarising educators with technology is a prerequisite for the smooth operation of the simulation program and appropriate student training. Being a simulation educator is not the same as being a nursing school professor. However, such distinctions are rarely made, and because health educators are under-trained and have limited skills, such training could be more effective (47).

Another significant limitation that may appear in simulation is incomplete training. A scenario that could be better designed may result in positive learning. For example, if specific physical reactions are not present during the simulation, students may disregard them and fail to test them. Due to time constraints, simulation frequently fails to assess some critical health care procedures and communication parameters. As a result, the students must ask for or obtain the patient’s consent before performing a medical procedure or following basic communication rules required to establish personal contact and create a healing environment (26).

The attitude of trainees is fascinating. Participants will always approach a simulator differently than they would in real life. On the one hand, there will be anxiety and concern because one is aware that a specific event will occur, but on the other hand, one may not pay attention because no one’s life is in danger (48)

Simulation educators and educators play an essential role in successfully implementing simulation programs. A nursing professor is not automatically associated with a simulation educator. Knowledge of technology and technological applications is required for successfully teaching nursing science parameters. A study conducted by Simes et al. (49) to investigate the factors influencing the comfort of simulation educators at an Australian university discovered four factors influencing educators: 1. Personal Barriers (including excessive stress from students’ expectations), 2. Structural Barriers (including an understanding of educational material and access to teaching and learning resources), 3. Human Resource Barriers (for example, when there is no prior information and discussion on simulation programs, and the students are given these programs and told to use them), 4. Suggestions for overcoming barriers (they provided suggestions for ways of addressing such barriers, including the presence of a mentor, more training in simulation-related issues, carrying out of a rehearsal and creation of backup copies).

Furthermore, according to a study by MacKinnon et al., the availability or lack of resources affects educators’ ability to participate in simulation activities in all courses of study (50).

Some students report that the role of an educator in simulation programs is critical and that it must combine the roles of a clinical nurse and an educator, as this is the only way to improve learning and the realism of various scenarios (51).

McAllister et al. (52) present recommendations for overcoming any barriers and limitations in simulation and maintaining quality in clinical training while considering practical and pedagogical issues. These suggestions include: assisting educators in their work, allowing students direct access to clinical skills videos, focusing on teaching clinical skills, utilizing teams in skill learning documentation, learning communication skills entertainingly and imaginatively, and improving time management and prioritization of needs for students.

3.6. Simulation’s Future in Nursing Education >

Nursing science and art play an essential and integral role in the healthcare system. Nurses and their training are critical components of the system’s effectiveness; therefore, special attention is and must be paid. Any changes in nursing education are intertwined with technological advancements and any technological means of teaching directly impact their education.

Simulation as an educational strategy presents a significant challenge for nursing education. Simulation has the potential to improve health care and patient safety. No living patient is jeopardized at the expense of the trainee. Simulation standardizes cases, encourages critical thinking, allows for patient care supervision, provides immediate feedback, and aids students in assimilating knowledge and experience. It is an excellent composition learning opportunity (53).

The introduction of virtual simulation is likely the most significant change in nursing education. The continuation and development of virtual simulation is a focal point for nursing science and nursing student advancement. This necessitates nursing schools investing funds in establishing appropriate laboratories, time for simulation as specified in curricula, and educators who are properly trained to create various scenarios and operate simulators. (54)

The virtual simulation must be integrated into the overall simulation program. Although virtual and augmented reality is still in its infancy, this option will quickly spread as simulation-related technology becomes more accessible and affordable. The quality of simulation devices will allow for student training in skills that previously required actual educators, opening up new opportunities for schools to reallocate their financial resources.

Aside from the acquisition of solid theoretical knowledge, nursing education’s goal is to acquire clinical skills, which are required for graduate nurses to be quickly integrated into the workforce. Nurses can provide quality health care using integrated learning, critical thinking, and optimal decision-making skills. This can be accomplished by incorporating simulation into the educational process. Further development of simulation and other educational methods may be very beneficial in students’ attempts to become integrated and prosperous healthcare professionals.
Jesus Garcia is a 28 years who was directly admitted to the medical unit on Tuesday evening with a diagnosis of dehydration. Fifteen days ago, Jesus underwent a partial colectomy with creation of a transverse colostomy. Jesus’ girlfriend Virginia has been taking care of him since discharge and reports that Jesus has resisted participation in colostomy care. Virginia needs to return to her full-time job and is concerned with how Jesus will manage without her at his side


In order to prepare for the simulation, you are required to complete the pre-briefing questions below and submit to the faculty facilitating the simulation prior to the start of pre-briefing. If you do not complete the pre-briefing questions below and submit to faculty facilitating the simulation prior to the start of pre-briefing, you will not be permitted to participate in the simulation.

Please keep in mind you will also be required to recognize a variety of signs and symptoms linked to abnormalities in these skills.


1. What are common signs and symptoms of dehydration?

2. What are complications you may see as a result of poor nutrition?

3. Describe nursing care and interventions for a client with a colostomy


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