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Year : 2012  |  Volume : 25  |  Issue : 1  |  Page : 11-15

The Use of Human Patient Simulators to Enhance Clinical Decision-making of Nursing Students

1 Walden University, Minneapolis, USA
2 College of Education, Walden University, Minneapolis, USA
3 Halix International, LLC, Yellow Springs; Wright State University, Fairborn, Ohio, USA

Date of Submission30-Jun-2011
Date of Revision12-May-2012
Date of Acceptance18-May-2012
Date of Web Publication30-Jul-2012

Correspondence Address:
S Powell-Laney
Walden University, Minneapolis MN
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1357-6283.99201

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Introduction: One of the newest teaching modalities in health education is the use of human patient simulators (HPS). A simulation scenario creates a software program vignette in which nursing, medical, and other students interact with a manikin to practice caring for patients in a risk-free environment. Although used extensively in schools of nursing, there is little research that examines if these expensive simulators improve the clinical decision-making ability of nursing students. The purpose of this quasi-experimental differentiated treatment study was to assess if HPS technology leads to greater clinical decision-making ability and clinical performance compared to the teaching modality of a paper and pencil case study. Methods: Students (n = 133) learning about the care of a patient with a myocardial infarction at four licensed practical nursing programs (LPN) in Pennysylvania, USA were randomly assigned to one of two groups at each site: an HPS simulation group or a paper and pencil case study group. One-tailed, independent t-tests were used to compare learning gains measured by differences in pre- and postclinical decision-making exam scores and clinical performance. Results: Results indicated that students in the simulation groups were significantly more likely to score higher on the clinical decision-making exams and to respond clinically by performing CPR more quickly on the manikin than students in the case study groups. On the 100-point exam, the simulation groups had a 20-point gain, while the case study groups had a 12-point gain (P < 0.001). Students in the simulation groups provided CPR to a manikin 30 seconds faster, on an average (P < 0.001). Discussion: Results validate the use of HPS technology in nursing education. Ultimately patients may benefit from increased knowledge and speed of care from practical nurses whose training was improved through the use of HPS technology.

Keywords: Clinical decision-making, clinical performance, critical thinking, human patient simulation, nursing education, problem-based learning

How to cite this article:
Powell-Laney S, Keen C, Hall K. The Use of Human Patient Simulators to Enhance Clinical Decision-making of Nursing Students. Educ Health 2012;25:11-5

How to cite this URL:
Powell-Laney S, Keen C, Hall K. The Use of Human Patient Simulators to Enhance Clinical Decision-making of Nursing Students. Educ Health [serial online] 2012 [cited 2023 Feb 4];25:11-5. Available from:

  Introduction Top

Human patient simulation (HPS) is a teaching method used in health practitioner education. Without a large body of research studies to support its use, health educators use HPS, otherwise known as simulators or high fidelity simulation, as a method for teaching critical thinking and clinical decision-making. [1] This study sought to explore the effectiveness of simulators in the preparation of students using an experimental differentiated treatment design across multiple sites. Previous studies of the effectiveness of simulators have largely been conducted in single settings measuring students' attitudinal perceptions.

Changes in the healthcare industry in the United States over the past decade, including closure of hospitals and decreased number of beds, have led to many challenges for nurse educators, including a shortage of clinical sites and supervisors. The simulator allows faculty to construct problem-based learning scenarios so students can "practice" clinical decision-making without risk to living patients. [2] Nursing is a profession of trust. Patients trust caregivers have skill sets necessary to assist them in recovery. [3] Teaching methods that increase the ability of the nurse to manage patient care should be used as much as possible in nursing education.

Much like aviation and aeronautics, healthcare is considered a high-hazard industry. [4] To reduce risk, repetition in responding to similar clinical problems and choosing a response for a variety of patients, such as those experiencing a myocardial infarction, should increase the ability of the healthcare provider to respond quickly and adjust for differences presented by each clinical scenario. [5] According to Jeffries, [1] the nursing education community has so embraced simulation technology that state boards of nursing in the United States are considering allowing the time-spent teaching simulation experiences to count towards the total number of hours that nursing students must practice in a clinical environment.

Nurse educators also need teaching methods that challenge and stimulate the interest and clinical decision-making skills of all nursing students. In many countries, the current generation of students is familiar with computers and the use of new technology. The ability to practice on a high-fidelity manikin may be a welcome and rewarding opportunity for these students, while eliminating risks to actual patients. Although simulation has been used in nursing education in the US for over 10 years and in other countries for longer, there is still a lack of research on the efficacy of the technology in increasing clinical decision-making ability of nursing students. [3],[6],[7] Health educators make decisions to allocate scarce resources. Simulators as teaching tools offer high-fidelity experiences but are expensive. Do simulators offer value to the teaching environment?

The purpose of this quasi-experimental differentiated treatment study was to investigate if the use of HPS technology leads to increased clinical decision-making ability and clinical performance compared to the teaching modality of a paper and pencil case study. Specifically, this study sought to validate the use of simulation technology as a teaching method for instructing practical nursing students in the care of a patient having a myocardial infarction.

Two research questions were investigated by this study: Do nursing students taught through pedagogy using a simulator (1) make better clinical decisions and (2) initiate cardiopulmonary resuscitation faster than nursing students taught through pedagogy using a paper and pencil case study?

  Methods Top

Participants in the study were students in five classes total (n = 133) in four similar public practical nursing programs within a 75 mile radius in western and central Pennsylvania in the northeast USA. (At one of the four sites, two classes participated.) All students had had some experience with simulation equipment, with an average of 45 hours reportedly spent in simulation labs prior to the experiment. The students admitted to the licensed practical nursing (LPN) programs had completed high school, passed a basic cardiopulmonary resuscitation course, and were 18 years or older. All states in the United States require the same licensing exam, but states' requirements for clinical training hours range from 900 to 1800 hours. This study was conducted over 3 days in May 2010. The steps to select the sample and assign participants to the experimental and control groups were approved by our institution's human subjects committee.

With 100% participation by students in the five classes, the 133 student study subjects (average size of the group in each of the five settings was 27) first viewed a 10-min PowerPoint presentation by one of the investigators (SPL) on American Heart Association (AHA) guidelines for care of the patient with a myocardial infarction prior to being randomly assigned to treatment groups. Previously, all student study participants had studied care of the patient with a myocardial infarction as part of their nursing classes.

Students then completed a pretest that contained three background questions concerning gender, age, and experience with simulation equipment and a pretest on knowledge about myocardial infarctions. Then, the 26 to 27 students in each of the five groups were randomly divided into groups of 13 or 14. The case study groups and simulation groups had experiences that were similar, except for the control variable of initial participation in a paper-pencil case study or a simulation with a human manikin. The amount of time needed to complete the educational and research activities for both the case study groups and the simulation groups was approximately 90 minutes.

The case study groups were directed to a classroom and given the pencil and paper case study to complete as a group in 15 minutes, followed by a posttest, which they took individually. The case study groups were then directed to the simulation lab where they participated in the simulation scenario with a SimMan manikin, as a team, and their clinical performance was measured by the amount of time it took them to perform CPR on the simulator. The case study groups then engaged in a 10-minutes debriefing, during which they were told how long it took for them to provide cardiopulmonary resuscitation.

While the case study groups completed the paper and pencil case study, the simulation groups were directed to the simulation lab and participated in the simulation scenario as a team. The scenario was 10 minutes long with a 10- to 15-minutes debriefing following the scenario and administration of the posttest, which was completed individually. The simulation groups then participated again together in an identical simulation scenario they had participated in prior to their first debriefing. Their clinical performance was measured by the amount of time it took them to provide cardiopulmonary resuscitation to the manikin. The simulation groups then had another debriefing session after the simulation scenario, during which they were told how long it took for them to provide cardiopulmonary resuscitation to the manikin. Debriefing has been found to be one of the most important parts of a simulation experience, as it allows students to reflect on their actions during the scenario and develop alternatives to their actions. [6]

Simulation scenario and paper and pencil case study used in the study were developed with consultation by three expert nurse educators who teach basic life support and advanced life support. After the three expert nurses came to agreement on the objectives, interventions, and desired outcomes to be included in the scenario and case study, one of the investigators (SPL) designed the case study and simulation scenarios and programmed the simulation software to "run" the simulation scenario. She also developed the pre- and posttest exams used in the study, which were reviewed by three nurse experts for content, congruency, and test construction. The three nursing experts categorized each question into the steps of the nursing process (planning, implementation, or evaluation) and rated the cognitive level of the question. All questions were tested at the application, analysis, and synthesis levels. (The case study and scenario materials and the pre- and postexams are available from the lead author.) The nursing experts achieved a 96% agreement that the items on the pre- and posttests were identical in terms of content, and nursing process level. Additionally, a psychometrician from Assessment Technologies Institute reviewed the pre- and posttests for congruency of types and numbers of items regarding application, comprehension, synthesis, and evaluation between the pre- and posttests. The test instruments were piloted with a group of 30 nursing students not involved in the study over a period of 3 months. Using Cronbach's alpha, reliability was estimated at 0.80. Sample questions from the pre- and posttest representing application, analysis, and synthesis are:

Application: A nurse observes a client in a long-term care facility lying on the floor with agonal respirations. The client has a faint but steady pulse. What is the nurse's next course of action?

  1. Begin CPR
  2. Administer two rescue breaths every 5 s.
  3. Call an ambulance
  4. Call a code.

Analysis: A client has been given a thrombolytic for a myocardial infarction with ST segment elevation. Which of the following symptoms should the nurse alert the client to report immediately?

  1. Chest pain
  2. Headache
  3. Shortness of breath
  4. Bleeding
Synthesis: A newly admitted ER client complaining of chest pain needs the following tasks completed:

  1. Administration of oxygen
  2. EKG performed
  3. Blood drawn for serum cardiac markers
  4. Aspirin given
  5. SL nitroglycerin administered
  6. History completed
Rank the order in which the tasks should be performed.

To investigate research question one regarding nursing students' clinical decision-making ability, pre- and postexams concerning care of a patient having a myocardial infarction were scored based on the percentage of correct items. Posttest scores were subtracted from the pretest scores for each student participant so the difference in learning gain between the pre- and post-exam for each student participant was measured.

To investigate research question two regarding clinical performance, the response time to cardiopulmonary resuscitation intervention was measured in seconds during a simulated patient's myocardial infarction with subsequent cardiac arrest, after the patient's heart stopped beating and the simulated patient's breathing stopped. The manikin software recorded the time from the moment of complete cessation of heart depolarization and breathing until the initial administration of effective breaths and compressions that constitute cardiopulmonary resuscitation.

Individual mean differences for pre- and postexam percentage learning gains (dependent variable) and group mean difference for time to intervention (dependent variable) were analyzed to compare students taught using either a case study or the simulation method (independent variable). An independent, one-tailed t-test was calculated to test for significant differences between these two groups after data were examined for normality and homogeneity of variance using Levene's F test.

  Results Top

The average age of the participants was 32 years and 88% were female. Regarding their understanding of responding to heart attacks, there was no pre-exam statistical difference between participants' knowledge. The mean score on the pretest was 49% for the simulation groups and 50% for the case study groups (P > 0.05). The mean scores on the posttest were 62% for the case study groups and 70% for the simulation groups (P < 0.001). The simulation groups had a 21-point learning gain in pre- to postscores compared to the case study groups which had a 12-point increase in scores (t = 3.56, P < 0.001). [8] [Table 1] presents mean pre- and postexam scores. [Table 1]
Table 1: Pre- and Postclinical Decision-Making Test Scores

Click here to view

The average time for the five simulation groups to provide cardiopulmonary resuscitation (CPR) was 32 seconds (SD = 12.8). The average time for the five case study groups to provide CPR was almost twice as long, at 62 seconds (SD = 22.2) (t = −9.62, P < 0.001). [8]

  Discussion Top

Significant differences in teams' posttest knowledge scores for how to respond to heart attacks and in teams' time to intervention in a simulated heart attack provide evidence that pedagogy incorporating simulation is more effective than the traditional case study approach for LPN students' clinical decision-making and performance.

This study may be useful for supporting nursing education practices and the requisite investment that can: (1) increase quality of care provided by nurses; (2) increase students' clinical decision-making skills, and (3) augment clinical instructional hours. Nurse educators can use the results of the study to help decide if their schools should invest in simulation technology to supplement their clinical training.

The pretest and posttest clinical decision-making exams used in this study tested the students at the application, analysis, and synthesis levels of cognition, very much like the National Council of State Boards of Nursing (NCSBN) licensing exam in the United States. [6] The significantly greater scores on the simulation groups' clinical decision-making exams and the significantly quicker time in the clinical performance test of the simulation groups compared to the paper-pencil case study groups could be explained by Dewey's [9] theory that greater learning takes place when students are able to interact with their environment. Problems and conflicts inherent in an environmental situation provoke thought and reflection from students. [4] As students repeat encounters, they are able to adapt to and solve problems. [2] Students in this study who were provided an "experience" were better able to react to and solve problems.

Traditional nursing education's clinical instruction in the United States revolves around faculty assigning students to one to two patients each clinical day. The amount of clinical learning that occurs for the student each day is left to chance; by graduation, students may never have encountered patients who allow them to develop some of the critical thinking skills needed to provide quality care to patients with a myriad of health conditions. Simulation can be used to supplement clinical instruction by allowing students the opportunity to "care" for patients with a wide variety of symptoms through highly structured, problem-centered teaching scenarios. Problem-centered learning, as simulation provides, holds promise for teaching nurses to become expert caregivers. [2],[5],[9]

This study's conclusions are limited geographically and by training level of students. Future studies could take place in different countries and also with medical, paramedical, and nurse training programs at different levels, and for medical conditions other than heart attacks. How much access to a simulator manikin results in maximum learning results could also be explored. Pedagogical approaches in using HPS could also be studied, exploring questions such as the best size of student learning teams collaborating in a simulation, the role of a nursing instructor in debriefing an experience with a simulator manikin, and value of reducing oversight to a less costly technician who programs the simulator. The expense of a HPS and the requisite training for faculty and possible smaller sizes of student groups add significant financial costs to medical training programs. Additional research will help institutions understand the value of HPS to help meet educational goals for students and training programs and career confidence and commitment by graduates to reduce turnover. Additionally, future research should evaluate if the teaching of critical incidents using simulation technology yields better patient outcomes. A longitudinal study of nursing students who have received critical incident simulation training in nursing school is also needed.

  References Top

1.Jeffries P, Rizzolo MA. Summary report-project title: Designing and implementing models for the innovative use of simulation to teach nursing care of ill adults and children: A national, multi-site, multi-method study, 2006. National League for Nursing and Laerdal. National League for Nursing data base. Retrieved on July 16, 2012, from   Back to cited text no. 1
2.McArthur Ravert PK. Use of a human patient simulator with undergraduate nursing students: A prototype evaluation of critical thinking and self efficacy. An unpublished doctoral dissertation, College of Nursing, University of Utah: Salt Lake City, Utah; 2004.  Back to cited text no. 2
3.Gers M, Niemer L, Pfendt K. Problem-based learning nursing education: A process for scenario development. Nurse Educator. 2010; 35(2):69-73.  Back to cited text no. 3
4.Gaba D. Out of this nettle, danger, we pluck this flower, safety: Healthcare vs. aviation and other high hazard industries. Simulation in Healthcare: Journal of the Society for Simulation in Healthcare. 2007; 2(4):213-217.  Back to cited text no. 4
5.Benner P. From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, CA: Addison-Wesley; 1984.  Back to cited text no. 5
6.Hicks F, Coke L, Li S. The effect of high-fidelity simulation on nursing students' knowledge and performance: A pilot study. National Council State Boards of Nursing Research Brief, 2009; Vol. 40.. Retrieved July 16, 2012, from   Back to cited text no. 6
7.Lasater K, Nielsen A. The influence of concept-based learning activities on students' clinical judgment development. The Journal of Nursing Education. 2009; 48(8):441-446.  Back to cited text no. 7
8.Gravetter F, Wallnau L. Essentials of statistics for the behavioral sciences. 5 th ed. Belmont, CA: Wadsworth/Thompson Learning; 2005.  Back to cited text no. 8
9.Dewey J. Experience and education. New York: McMillan; 1938/1997.  Back to cited text no. 9


  [Table 1]

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