Running head: SIMULATION: AN INNOVATIVE TEACHING TOOL
Simulation: An Innovative Teaching Tool
Diane C.
Ferris State University
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SIMULATION: AN INNOVATIVE TEACHING TOOL
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Abstract
The purpose of this paper is to demonstrate to McLaren Regional Medical Center’s stakeholders
the need for the use of simulation in health-care education in a dedicated, on-site, simulation
laboratory. This paper discusses simulation, research studies that support its use, a plan for
implementation, educational and nursing theory that fosters simulation, and evaluation strategies.
Using theory along with evidence-based studies justifies how simulation can innovatively be
used to promote this technical method of learning and ultimately have a positive effect of the
quality of patient care.
SIMULATION: AN INNOVATIVE TEACHING TOOL
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Simulation: An Innovative Teaching Tool
The ever-increasing complexity of health-care environment requires not only a strong
clinical knowledge base but also expert clinical reasoning (Jeffries P. R., 2007). With over 1500
health-care professionals, McLaren Regional Medical Center (MRMC) is no exception. The
open heart program, a stroke center for excellence, a bariatric center for excellence, a level two
trauma center, and most recently the introduction of a proton beam therapy center for cancer
treatment are just a few examples. As hospitals continue to expand and improve their health-care
services, nursing education departments must prepare health-care providers with equally
innovative knowledge and skills. By combining traditional teaching practices with state-of-theart technology, nursing education departments can provide health-care providers with an
essential component to learning: simulation.
The purpose of this paper is to introduce the innovative method of simulation. This paper
discusses the importance of simulation, research in simulation, educational and nursing theory,
identifing and engage stakeholders, and evalaution of the simultion implementation. A
simulation process will improve nursing practice and will assist in providing safe, quality patient
care. This initiative will result in positive patient outcomes (Jeffries P. R., 2007).
The financial component including the cost of a patient simulator and the costs affiliated
with maintenance have already be approved by the MRMC board. The location for the
simulation has already been addressed and approved. The McLaren Foundation has donated
monies to cover all costs assocaited with the simulation lab.
Importance of Simulation
SIMULATION: AN INNOVATIVE TEACHING TOOL
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Nursing Practice
A nursing faculty shortage combined with a nursing shortage has created an opportunity
for the nurse educator to develop more innovative teaching modalities (Campbell & Daley,
2008). The competency of the new generation of nurses in new technologies poses a challenge
for hospital nurse educators to provide innovative support to health-care providers (Campbell &
Daley, 2008). A solution is to provide education combining traditional teaching with state-of the-art technology and calling it simulation.
The International Nursing Association for Clinical Simulation and Learning (INACSL)
2011 has identified seven Standards of Best Practice:
 Terminology – standardized terminology promotes consistency between disciplines.
 Professional integrity of participant – participant is expected to adhere to the Health
Insurance Portability and Accountability Act (HIPPA) standards and professional
conduct standards.
 Participant objectives – scenarios will be individually focused in relationship to subject
and experience level.
 Facilitation methods – scenarios will facilitate multicultural and trans-generational
learners.
 Simulation facilitator – trained facilitator is present to maximize learning potential.
 The debriefing process – mandatory time to reflect and implement clinical reasoning based
on evidence-based knowledge.
 Evaluation of expected outcomes – based on proven evaluation processes (INACSL, 2011)
MRMC is a large teaching hospital that offers many services all of which need to be
taken into account when designing the simulation program. Flint, Michigan is a city that is
SIMULATION: AN INNOVATIVE TEACHING TOOL
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multicultural and the needs of the multicultural patient will be incorporated into the program. By
utilizing the guidelines from the INACSL MRMC will be succeessful in developing an
educationally solid simulation program. The simulation program will be an educational process
that will help healthcare providers who work at the bedside bedside have the skills to care for the
diverse pateints MRMC receives.
Improved Patient Outcomes
A simulation process will improve nursing practice that assists in providing safe, quality
patient care resulting in positive patient outcomes (Wayne, Didwania, Feinglass, Fudala, Barsuk,
& McGaghie, 2008). The simulation lab offers a place for health care providers to practice in a
setting that cannot endanger patients. Simulations that include skill and drill training,
interactivity, and exposure to rare cases can greatly improve patient safety (Rall & Dieckmann,
2005).
By nurses utilizing a simulation method of learning increases autonomy, promotes
communication, and collaboration (Radhakrishman, Roche, & Cunningham, 2007). This gives
the opportunity for the individual to perfect one’s skills (Radhakrishman, Roche, &
Cunningham, 2007). The healthcare provider is able to practice with the use of real situations.
This can decrease the individual’s anxiety (Pothier, 2006). This action is critical to the outcome
of the patient as repetition and confidence is shown to increase with simulation preventing risks
to patients (Pothier, 2006). Decreasing risks to patients directly relates to improved patient
outcomes.
History and Research Supporting Simulation
History
SIMULATION: AN INNOVATIVE TEACHING TOOL
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Simulation was originally developed to provide training for high-risk workers such as
airline pilots and military personnel (Galloway, 2009). The result was that despite the natural
dangers pilots and military personnel experienced a low percentage of accidents occurred
(Galloway, 2009). In an effort to maintain a safe clinical environment The Health Professions
Education Foundation (HPE) slowly investigated integrating simulation in health-care
(Galloway, 2009).
Two developments in technology that influenced the growth of simulation were the debut
of The World Wide Web, August 6, 1991, and the completion of the Virtual Human Project in
November, 1995 (Bellis, 2011; United States Library of Medicine, 2011). Adding affordable,
portable human simulators to the above stated technological milestones catapulted simulation
and health-care education into a new dimension.
Research Studies Supporting Simulation
The following studies were all done in a hospital setting. Because these studies took
place in a hospital they will be used because they directly relate to a practice setting.
A study was completed at Northwestern Hospital in Chicago with residents placing
central venous catheter (CVC) lines (Voelker, 2009). The rate of blood stream infection was
monitored prior to 92 residents being given simulation training in placement CVC lines. The
study occurred over a 32 month period and revealed that the rate of blood stream infection
decreased to 0.50 per 1000 catheter days from 3.20 per 1000 catheter days from the simulation
training (Voelker, 2009). This data supports that simulation training helped improve positive
patient outcomes related to bloodstream infections from CVC lines.
A study completed by Radhakrishnan, Roche, and Cunningham (2007) compared
Bachelor of Science in Nursing (BSN) students who were educated using Human Patient
SIMULATION: AN INNOVATIVE TEACHING TOOL
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Simulators (HPS) as well as a 320 hour clinical practicum with a preceptor against a BSN group
that only had the 320 hour clinical practicum experience. The groups were evaluated at the end
of the semester by the faculty and scored on a list of behaviors that should be preformed when
assessing and caring for patients. The results were that the group that had exposure to the HPS
scored higher in areas of patient safety and assessment skills (Radhakrishnan, Roche, &
Cunningham, 2007). This indicates that the use of stimulation directly correlated to improved
practices which results in patients receiving a higher level of care by students being trained with
a simulation experience. Based on this study it is inferred that using a simulation activity with
health care providers would allow them to review practice resulting in better patient care.
Another study by Bambini, Washburn, and Perkins (2009) supports the use of simulation.
This study examined nursing students being exposed to simulation education related to the
postpartum and care of the newborn. The effect the simulation experience had on these students
was an improvement of their confidence, their therapeutic communication, and their clinical
judgment.
Simulation in Nursing
The Role of the Nurse Educator
The education of nurses is the responsibility of the nurse educator. The nurse educator
transfers her knowledge to act as a facilitator. The nurse educator must be able to ask high level
questions and promote clinical reasoning (Jeffries P. , 2005). The debriefing component of
simulation encompasses this role. The knowledge gleaned from simulation directly impacts the
nurse in caring for the patient. This results in a nurse that is able to learn from the actions
displayed, as well as being able to clinically reason ways to render quality care to the patient.
SIMULATION: AN INNOVATIVE TEACHING TOOL
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It is the responsibility of the nurse educator to make sure that the simulation experience
follows the learning cycle (Mashburn & Neill, 2002). The learning cycle has four stages:
motivation, comprehension, practice, and application (Mashburn & Neil, 2002). In order to lead
the student through the learning process the nurse educator needs to make certain that the
competency (in this case the simulation program) has all the components of the learning process.
In the first stage of motivation the educator needs to create ways to encourage the student
to learn as well as understand what the student needs to learn from this process. The second
stage of comprehension the educator needs to emphasize to the student the need and reason for
the education experience. The educator also needs to explain what is required of the student, for
example what textbook portion the student will need to read. In the third stage, the student will
move from the comprehension stage to the practice stage by the educator guiding the student
through the practice. This stage occurs when the nurse educator is involved in the simulation
with the students. The last stage application is when the student is able to practice the skill
without the need of the instructor. At this stage the student should be able to complete the
learning cycle and apply the skills they have learned with little guidance from the instructor
(Mashburn & Neill, 2002). Appendix A displays how the student moves clock-wise through the
learning process.
Accountability in Nursing Practice
The advanced practice nurse educator, in the practice setting, educates staff on how to
take care of the patient population (Pothier, 2006). Responsibilities associated with maintaining
safe, quality patient care, according to the American Nurses Association (ANA), Nursing’s
Social Policy Statement: The Essence of the Profession (2010), are:

Analyzes and addresses factors related to quality and safety of patient care.
SIMULATION: AN INNOVATIVE TEACHING TOOL

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Demonstrates leadership by designing and implementing educational activities to
improve quality.

Uses up-to-date evidence-based findings to update the healthcare professional’s
knowledge, skills, abilities, and judgment in order to enhance their performance.

Incorporates evidence to justify change.

Uses innovation to improve patient care.

Implements activities to enhance the quality of nursing care.
In addition to complying with the ANA statements, the nurse educator is also responsible to
comply with the ANA Scope and Standards of Practice (2010). The ANA requires the
advanced nurse educator to provide leadership in the design and implementation of innovative
programs. Innovative design implementation is also supported by The Scope of Practice for
Academic Nurse Educators, Competency V: Function as a change agent and leader (NLN, 2005).
Benner’s Nursing Theory
Patricia Benner’s nursing theory of clinical nursing practice from novice to expert is
supported by simulation (Covington, Foster, Larew, Lessans, & Spunt 2006). Benner describes
that the nurse will advance through different levels of development in nursing practice, from
novice, to advance beginner, to competent, to proficient, and to finally expert (as cited in
Alligood & Tomey, 2010). Benner and colleagues (1992) discuss that in order for the nurse to
progress to the different levels of practice they attain different skills (as cited in Alligood &
Tomey, 2010). To progress from the novice stage to that of an expert nurse must progress
through four levels of performance:

The nurse moves from relying on the concepts that were taught to that of experience.
SIMULATION: AN INNOVATIVE TEACHING TOOL
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
The nurse utilizes the skill of intuition.

The nurse displays understanding that the patient needs to be evaluated holistically and
that each component needs to be assessed.

The nurse utilizes the skill of intuition.

The nurse displays understanding that the patient needs to be evaluated holistically and
that each component needs to be assessed.

The nurse assumes full participation in the patient’s care and understanding of the
actions. performed (Alligood & Tomey, 2010).
Since simulation can advance the level of the nurse’s practice, simulation can be applied
to Benner’s Theory, from novice to expert (Covington et al., 2006). The simulation that is being
taught for ACLS, for example, can support the novice nurse, while still providing a demanding
situation to the expert nurse (Covington, Foster, Larew, Lessans, & Spunt 2006). The nurse
educator will also be able to assess the nurses’ level with ease by utilizing Benner’s Theory. The
art of simulation will allow to the nurse to progress through the different stages of Benner’s
Theory while still providing the challenge and growth to the expert nurse.
Engaging the Stakeholders in Simulation
Presentation to Stakeholders
In order to implement the simulation, the idea needs to be presented to all the
stakeholders at MRMC. The first group would include the Vice President of Nursing Services,
the Directors of Patient Care Services, the Director of Research and Education, the Vice
President of Finance, the Vice President of the McLaren Foundation, and the Chief Executive
Officer. These stakeholders would need to see firsthand the benefits of simulation to the nursing
staff and understand the correlation to the care patients receive. I would formally invite all the
SIMULATION: AN INNOVATIVE TEACHING TOOL
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stakeholders to a brunch held on MRMC campus in the Ballenger Auditorium. The following is
an overview of my presentation:
1. Create a Basic Life Support (BLS) demonstration for the stakeholders at MRMC by
utilizing the simulation props from Mott Community College.
2. Have the Director of Mott Community College’s simulation lab be available to
answer and questions and to support the use of simulation at MRMC.
3. Explain to the stakeholders that there are multiple areas in which the nurses could
benefit from education simulation.
4. Provide three evidence-based articles to all stakeholders outlining simulation as a best
practice in education of nursing staff. I would also focus on the benefit of the improved
care the patient would receive at the MRMC by this change.
5. Provide time for questions and answers. Suggest a visit to Mott Community College
to see simulation in action with actual students if interested.
Introduction to Nursing Staff and Nursing Leadership
Once support was received from the Executive Leadership Team, I would present the
simulation idea to the nursing staff including nurse educators and nurse managers.
I would provide the simulation with the example of the Advanced Cardiac Life Support (ACLS).
This demonstration of simulation would occur multiple times over a seven day period
in order to interact with as much staff as possible. I would also set up a video
presentation of other simulation cases and hand out evidence-based studies to support simulation.
In order to get an idea of what the nursing staff would like to see I would seek their feedback
during these sessions by having a flip chart available where they could write down their
SIMULATION: AN INNOVATIVE TEACHING TOOL
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thoughts. I would then relate this to the executive leadership to show support of the simulation
lab.
Herzberg’s Dual Factor Theory of Motivation and Job Satisfaction
In order to increase the motivation with the nursing staff in the acceptance of simulation I
would utilize Herzberg’s Dual Factor Theory of Motivation and Job Satisfaction. Herzberg and
colleagues first developed the theory in 1959, which focused on ways to increase job motivation
and satisfaction (as cited in Ewen, 1964). One way to accomplish this was to create behaviors to
ensure the work that the individual was doing was challenging and inspiring (Burke,1966). This
theory involves two factors, the hygiene factors and the motivational factors (Burke,1966).
Hygiene factors include the relationship with the nursing education team that would be providing
the simulation education (Burke, 1966). These factors include how easy the process would be to
utilize simulation, the interactions during the simulation and the support from the nurse educators
during the debriefing process. High levels of absence in these factors lead to
dissatisfaction (Burke, 1966). Therefore the staff would not be motivated to use the simulation
technique for education.
The motivators in simulation are the achievement of increased education, the increased
level of autonomy to act in the simulation lab, and recognition they would receive from their
peers and nurse educators during the simulation process (Burke, 1966). Staff would also receive
recognition from their manager for utilizing the simulation lab. High levels of these factors are
associated with highly satisfied individuals (Burke, 1966). Therefore the staff member would
utilize the simulation lab and increase their knowledge level in order to provide excellent care to
their patient.
Herzberg’s theory focuses on the level of satisfaction felt by the staff member.
SIMULATION: AN INNOVATIVE TEACHING TOOL
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Simulation focuses on the individual’s autonomy that results in the person having the
knowledge to perform the necessary skills to take care of their patient (Jeffries, 2007).
This leads to an increase in the individual’s confidence which in turn promotes their self
worth and satisfaction in their job (Jeffries, 2007). Soliciting input from staff during
the introduction of simulation will help to obtain information that will enable the successful use
of Herzberg’s theory. The nurse educator seeking to increase the development of the staff nurse
support The Scope of Practice for Academic Nurse Educators, Competency II: Facilitate Learner
Development and Socialization (NLN, 2005).
Evaluation of Simulation
The simulation lab, upon physical completion, will be staffed by MRMC educators until
usage data supports alternative staffing. A positive evaluation measure would be a substantial
number of simulation participants. The lab will begin with ACLS algorithm scenarios. I have
spoken with Don Adams (Director of Emergency Medical Services EMS), who will provide
simulation trainers for ACLS classes (Don Adams, personal communication October 28, 2011).
ACLS certification must be renewed every two years to be valid (Don Adams, personal
communication October 28, 2011).
An evaluation will be done to evaluate the effectiveness of simulation learning associated
with ACLS. A baseline percentage of the number of in-patient cardiac arrests who recover a
sustainable rhythm and survive for 48 hours pre-simulation will be evaluated after one year and
again after two years of ACLS simulation education.
Another way to evaluate the simulation process is by participant evaluation. Jeffries
(2007) utilizes a Simulation Design Scale for evaluation (see Appendix B). Utilizing this
SIMULATION: AN INNOVATIVE TEACHING TOOL
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document and evaluating the findings will show areas that need improvement as well as areas
that are successful in order to make necessary changes to the simulation program.
Conclusion
The paper has presented the positive impact of simulation on improved nursing practice
that results in improved patient care (Wayne, Didwania, Feinglass, Fudala, Barsuk, & McGaghie,
2008). In order to keep MRMC’s health-care providers competently trained to care for the
complexities that come with high-tech medical care, education using simulation is a necessity.
The complexity of multifaceted patients cared for at MRMC requires bedside nurses to have not
only a strong clinical knowledge base but also expert clinical reasoning.
Studies have been presented validating that simulation increases nursing autonomy,
promotes communication, and collaboration. Giving individuals the opportunity to perfect one’s
skills will improve patient care and patient satisfaction. (Radhakrishman, Roche, & Cunningham,
2007). The use of innovative practices is not only supported by the INACSL, the ANA, and the
NLN but also by Benner’s nursing theory.
MRMC has shown its commitment to quality care as evidenced by the open heart
program, the stroke center for excellence, the bariatric center for excellence, the level two trauma
center, and the introduction of a proton beam therapy for cancer treatment. Thus MRMC will
continue its commitment to excellence in health-care education and patient care using the
innovative educational method of simulation.
SIMULATION: AN INNOVATIVE TEACHING TOOL
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References
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SIMULATION: AN INNOVATIVE TEACHING TOOL
Appendix A
Figure 1: The four stages of the learning process (Mashburn & Neill, 2002, p. 180).
4
1
APPLY
MOTIVATE
PRACTICE
COMPREHEND
3
2
18
SIMULATION: AN INNOVATIVE TEACHING TOOL
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Appendix B
Table 1
COMPONENT
Sample Items from the simulation Design Scale (SDS)
SAMPLE ITEMS
Objectives/
I clearly understood the
information purpose and objectives of
the simulation.
The cues were appropriate
and geared to promote my
understanding.
Student
My need for help was
Support
recognized.
I was supported in the
learning process.
Problem
I was encouraged to
Solving
explore all possibilities
during the simulation.
The simulation provided
me with an opportunity to
set goals for the patient.
Fidelity
The scenario resembled a
real-life situation
Debriefing
Feedback provided was
constructive
(Jeffries P. R., 2007, p. 95)
STRONGLY
DISAGREE
DISAGREE
1
2
NEITHER
AGREE
NOR
DISAGREE
3
AGREE
STRONGLY
AGREE
4
5