What is the Role of Simulation in Nursing Education?

From The Floor

What is the Role of Simulation in Nursing Education?

By Genevieve M. Clavreul, RN, Ph.D.
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“Tell me, and I will forget. Show me, and I may remember. Involve me, and I will understand.” — Chinese Proverb

The above proverb, sometimes attributed to Confucius, encapsulates a core component of nursing education — the use of simulation labs during clinical rotation. Back in the day when my peers and I attended nursing school, we didn’t have “Sim Man” to practice on. During clinical, a nursing student was expected to apply their textbook learning by experimenting on other students in class. Even more scary, we practiced on patients on the hospital floor under the eagle eye of our preceptor, mentor or other assigned supervising nurse.

These moments of interaction were fraught with concerns that a crucial mistake could harm a real human being. Many student nurses found those clinical experiences too much to bear and ended their nursing careers before they began.

Meet Annie

In 1960, a Norwegian toy maker by the name of Åsmund S. Laerdal developed a mannequin. Based on the research of Peter Safar and James Elam, it accurately simulated the human respiratory system and external body landmarks to facilitate the training of cardiopulmonary resuscitation (CPR).  Nicknamed “Resusci Annie” (or “Rescue Annie”), she was used to teach CPR to both the layman and the healthcare professional.

Today, Resusci Annie can be found in many forms, including a male (Resusci Andy), and in varying degrees of sophistication; some include computers that simulate other medical emergencies, such as severe wounds and trauma.

Early Resistance

Simulator training was invented in the 1990s, but its educational use was met with resistance from the nursing community and licensure bodies. Gradually attitudes changed. Then, in 2005, the National Council of State Boards of Nursing (NCSBN) published a position paper on clinical education advocating “…the inclusion of innovative teaching strategies that complement clinical experiences for entry into practice competency.”

The reasons why simulation is coming into acceptance include patient safety, better preparation of new nurses, overcoming faculty and preceptor shortages, and, most of all, expanding the availability of clinical sites. This dovetails with recent trends in nursing education, such as the increase in online learning.

Almost the Real Thing

At present, there are six recognized types of simulation. They are:
• screen- and PC-based simulation
• virtual patients
• partial task trainers
• human patient simulator
• standardized patients
• integrated models

All six models of clinical learning have their advantages and disadvantages. PC-based simulation and virtual patient simulation both offer easy and flexible access, accommodate an individual pace of learning, are recommended for entry or lower-level students and have a relatively low cost. On the other hand they also share the following disadvantages: low fidelity, no or limited experiential learning or physical interactivity.

Task trainers, while low-cost and wonderful for procedural practice, have low fidelity.

Human patient simulation and standardized patients are good for higher-level students, provide a higher realism and a more interactive experience, and provide more opportunity for the use of critical thinking, decision-making and delegation. There are two major limitations – high cost and dependency on availability of human instructors/operators. The standardized patient offers the further challenge of having a patient whose signs don’t always match the symptoms needed for the learning experience.

State Decisions

A 2006 NCSBN survey (Nehring 2006) was designed with the purpose of examining the status of regulation changes concerning the use of simulation in nursing programs; and if no regulation changes, what presence, if any, of the approval for use of simulation.

Forty-four states, the District of Columbia and Puerto Rico participated in the survey, and:
➢    Five states and Puerto Rico have changed nursing regulations to allow a percentage of clinical time with the simulators,
➢    Florida specified that 10 percent of clinical time to be replaced by simulation experience,
➢    While there was no changes in regulation, sixteen states give permission for schools to use a percentage of their clinical time with the simulation experience, and
➢    Percentage is determined on a case-by-case basis.

Though the California State Board of Nursing didn't participate in the NLN study, they allow the use of simulation up to 25 percent of any clinical course.

Complimentary Role

Students entering school today have had a lifetime of using computers and their related technology. Many play high-resolution games with graphics so realistic that one can hardly differentiate between computer generated graphics and real-life: just ask anyone who watched Avatar if you have any doubts. The incoming and future nursing student will most likely see an
expansion and greater acceptance of simulation. Such training can only complement nursing education and greatly reduce the anxiety the student nurse may experience during clinicals.

One can hardly attend a nursing conference these days without seeing Sim Man manufacturers hosting booths and seminars. We can only expect their presence to grow in the coming years.

We’ve come a long way from Resusci Annie in the ‘60s with her limited role as a CPR instructional dummy. She evolved into the early Sims introduced in the ‘90s, to those of today with their real-life symptoms, such as responding to medication error, mimicking pain and side effects, and even giving birth to their own Sim Baby who, in turn, can produce a whole host of symptoms. 

Simulations cannot and should not replace the role of the human patient in the clinical experience; but, they are an invaluable addition to the nursing school and clinical educators’ bag of tricks. In their proper role they can truly enhance the student nurse’s learning experience. 


Geneviève M. Clavreul RN, Ph.D., is a healthcare management consultant who has experience as a DON and as a lecturer of hospital and nursing management. She can be reached at: (626) 844-7812; gmc@solutionsoutsidethebox.net


Rescue Annie“The Most Kissed Face”

L’Inconnue de la Seine (French for “the unknown woman of the Seine”) was an unidentified young woman whose death mask became a popular fixture on the walls of artists' homes after 1900. Her visage was the inspiration for numerous literary works — and one very practical one.

According to an often-repeated story, the body of the young woman was pulled out of the Seine River in Paris in the late 1880s. The body showed no signs of violence, and suicide was suspected.

At the time, bodies washed up on the riverbanks were displayed for the public in hopes of identification. But nobody came forward to claim this girl, who was estimated to be 16 years old.

A pathologist at the Paris morgue was so taken by her beauty that he had a plaster cast death mask made of her face. In the following years, numerous copies were produced which became a fashionable
morbid fixture in Parisian Bohemian society.

The face of the unknown woman was later used for the likeness of the CPR mannequin Rescue Annie, marketed by Asmund Laerdal in 1960. Ironically, the unknown woman of the Seine has been called “the most kissed face” of all time.

This article is from workingnurse.com.

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